Treatment decision-making:how do you prefer to work with your doctor?

There are a wide range of ways we can arrive at treatment decisions with our prostate cancer doctors.

(1) Some of us prefer to find a highly reputable doctor and assent to letting him make the choices for us, understanding that he is acting in our best interest.

(2) Some of us prefer to be fully informed of all risks and benefits of the alternative treatments, but prefer that the doctor take responsibility for the decision.

(3) Some of us prefer to use our doctors as health consultants – there to inform us of risks and benefits of the alternative treatments, but stopping short of a recommendation. The decision is then left to us.

(4) Some of us prefer to be fully informed of all risks and benefits of the alternative treatments, and prefer an interactive discussion where the doctor comes to understand our values, attitudes and lifestyles, and we arrive at a consensus with our doctors.

Which do you prefer? There are no right or wrong answers, just individual preferences. However, the way we prefer to interact with our doctors, and the way they prefer to interact with us can create either conflict or consonance.

I raise this issue because, for the bulk of us, the recent AUA guidelines on PSA screening call for shared decision making (#4 above) facilitated by Patient Decision Aids. It represents a paradigm shift in the doctor-patient relationship. It will take more of the doctor's time, and forces the patient to verbalize his own values and desires, and take more responsibility for the decision.

The AUA guidelines said...

Shared decision making. Shared decision making between clinicians and men is a strategy for making health care decisions when there is more than one medically reasonable option. Each choice has different patterns of outcomes, and the values a man places on those outcomes need to be considered in order to make an optimal decision. Such decisions are said to be "preference sensitive." The characteristics of a shared decision making process include involvement, at minimum, of a clinician and man in the decision making process (although others may be invited in by either party), bilateral sharing of information, joint participation in the decision-making process and then reaching agreement on a management strategy to implement. Men should be able to invite others, such as a spouse, friend or family member into the process; however, it should not simply be assumed the man wants anyone else to participate. The bilateral information sharing involves the clinician helping the man understand their options and the risks and benefits of each option, while the man helps the clinician understand what matters to them in the context of the decision. From the clinicians' perspective, understanding a man's values and preferences can be seen as a diagnostic task, as important as the diagnosis of disease in a man presenting with symptoms. Shared decision making contrasts with a more paternalistic style of decision-making, where clinicians tell men what they should do, often based on their own values and preferences.

Post Edited (Tall Allen) : 5/11/2013 12:52:47 AM (GMT-6)

I also went with #4, but am thinking I hit the wrong button???

It's showing one #3 and one #4.

I chose #3 Ms. WW.
I was joking above. I am in charge, a consensus might not always be available.

Tony

I am still in the descision making phase of my treatment, having been recently Dx. I find myself somewhere between 3 and 4, but I certainly want to call the shots, while having a good collaboration with my doctor. I want a doctor who listens to my concerns and answers openly. I'm not the expert, but I'm not a child either. I've done a LOT of my own research and feel I can have an intelligent discussion with any doctor. I have already dismissed one urologist for cutting me off mid-sentence too many times and not listening to me. I listened to him, but in the end, I'm not ready to turn my life over to someone who won't take the time to talk and listen to me. I understand the value of having an
expert", but even an expert has a bad day. I want someone who is working with me and for me.  At the end of the day, they put their pants on the same way I do.

I agree David that skill is more important than bedside manner. I think part of the skill should be listening as well. I'm not saying I will always like the answers, and I understand that, but I deserve answers to my questions as well. I should have been more clear. I don't have to be pals with my doctor, but when I ask for specifics, ie: "what is your definition of incontenace success?, how many surgeries have you performed?, etc. I should be able to get a straight answer and not just be told what to do.

Almost feel like the questions are being tilted to prove a point, but then that can be said about any survey, the devil is in how questions are being asked.

I am assuming we are only talking about the doctor that is primarily treating our prostate cancer, correct?

If I were in the ER for emergency reasons, then #1 would be the obvious answer.

As far as playing along with this, I choose #4 - but with a qualifier.

Been with my great oncologist for 2 years this month. We have taken a teamwork method since the start. He's very interested in my input, letters, e-mails, phone calls, in person extensive conversations, etc. As he says, wishes more patients were like me, those able to communicate so openly, and someone that is very in-tune to their body. He says he's not a mind reader, the more I can tell him, the better he can treat me.

Having said that, while much of what has happened since I have been with him has been mutually agreeable decisions, he is the doctor, I am the patient, he is the advanced PC specialist, I am not, when push comes to shove, he will always get the final word, and if there is a split decision, he gets to break the tie. I respect his depth of knowledge, his caring heart, and his approach.

We all know that bed side manner never trumps skill and experiences, but there's no reason for a doctor to act like an a.h toward his patients, or to be playing the "god" card, or to be on some other kind of ego trip. My doctor works for me, not the other way around. I feel fortunate to have a great doctor with great personal skills and a truly compassionate heart.

My average "face time" with my doctor is one full hour. He takes the time to listen, no matter how busy he is, he never looks at his watch or clock in the room, and a visit isn't over with till every last question and concern I have have been fully answered.

david in sc

jim, which david were you answering? it gets confusing with all the david's. that's why I usually sign david in sc, and then davidg usually signs that way.

david in sc

These doctor/patient interaction styles are based on the research of Cathy Charles et al "Shared decision making in the medical encounter: What does it mean? (or it takes at least two to tango)" Soc. Sci. Med. Vol. 44, No. 5, pp. 681-692, 1997. The four choices reflect differing needs for information, and differing desires to take responsibility for treatment decisions.

#4, while it may sound good in theory, involves a lot of work on the part of both the patient and the doctor. The doctor has to be willing and able to explain a lot of medicine to a patient who may not be well-versed in the field, and he has to be willing to change his treatment plan based on the patient's input, sometimes putting his own values and ego aside. The patient must be prepared to absorb a lot of unfamiliar information, ask a lot of questions, articulate his feelings and values, and take a lot more responsibility for the final treatment decision. A new industry creating patient decision aids has sprung up to facilitate this.

My brother is a good example of the #1 type. Although he is brilliant, he says, "I don't want to go to school every time I visit my doctor. My doctor is tops in his field, so who am I to question him? He is also my best friend and I know he has my best interests at heart -- whatever he says goes." His doctor/best friend is also willing to take on that responsibility.

There's someone in my PC support group who exemplifies #2. We went into a meeting to his radiation oncologist together. He had some questions, and was very interested in what the doctor had to say over the next hour, in that case about the risks and benefits of adjuvant vs salvage radiation. The doctor finally asked him which course he preferred. He responded by turning it around and asking the doctor what he would do if he were in his place. Although I convinced him to not decide then and there, he made it clear to me that he would go with whatever the doctor recommended - in his case, adjuvant radiation.

#3 puts the burden more on the patient. Some doctors do not like to work this way, and will recommend the patient find another doctor who does. Other doctors relish not taking on themselves the full responsibility for the treatment decision. It also puts more burden for understanding all the information onto the patient. I was lucky to find a urologist and a radiation oncologist who work with me in this fashion.

I wish I could poll our doctors to see the interaction style they prefer. The doctor has the additional burden of having to deal with patients who prefer four very different styles.

TC-LasVegas said...
I chose #3 Ms. WW.
I was joking above. I am in charge, a consensus might not always be available.

Tony

Gotcha! I thought I had a senior moment!

I agree, we are in charge. #3 and #4 are so closely worded. The word "consensus" swayed me from #3. If no consensus, we reach out to get one. Hence, Dr. Scholz being added to the team. We have all now come to a consensus.

Post Edited (MsWorryWart) : 5/11/2013 12:33:25 PM (GMT-6)

Good point, Jim. It's not always a one patient-one doctor dyad. Often there is more than one person on the patient "side" (e.g., spouse, friend, relatives, people on internet boards) and more than one on the doctor "side" (e.g., second opinions, other specialists, nurses). I admire your team approach.

who here hasn't "called the shots"?

That question reads like someone puts a gun to your head.

Then they're calling the shot to decide what is best for them based on what their doctor or doctors suggest and to what extent they'll accept the medical advice. They're still calling the shots one way or another.

My first urologist immediately mentioned surgery, radiation and AS and then gave his personal opinion on what was the best treatment for me given my particulars.

All of us use doctors as an information source, I'm very surprised that you would think some/many don't. Information is always passed along. And I imagine that all doctors discuss potential impacts of treatments and how to mitigate them.

Everyone here knows something about PCa, where do you think they start learning about that form?

For me #3 and #4 are very similar but I chose #3. Option #4 is the only option that is making an assumption- that you and your doctor can achieve a consensus. What if you can't achieve a consensus? You are left to choose one of the other options.