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Sorry, Doc, that doesn't fit my schedule (Feb-04)

Patients sometimes skip treatments because they just feel too busy. What should physicians do when their patients ignore their recommendations?

Imagine you are a businessperson who works long hours and you are on your way up to having a successful and lucrative career. You have a major business deal that will consume nearly all of your time over the upcoming month and your boss is relying on you to make sure the deal goes through. This is your chance to really make your mark and show your corporation that you are the kind of person that can handle deals as big as this one. Also suppose you have been smoking on and off for 25 years. You know it's a bad habit that could destroy your lungs, but you just can't quite kick it. Lately, you have been feeling tired, you have been experiencing chest pains when you are really busy at work and when you exercise, and you have had trouble breathing when climbing a flight of stairs. The chest pains are usually relieved by a little rest, but you decide it's time to get this examined by a doctor.

One day after work, you go to see Dr. Coral, who gives you a stress test and determines that you'll need an appointment for an angiogram to better evaluate your coronary arteries. Fortunately, you find one free day right before things get hectic at work, so you schedule the angiogram. Now imagine you have just had the angiogram and you are recovering in a paper gown waiting for Dr. Coral to come back with the results. Dr. Coral enters the room to speak with you and he has a serious look on his face. He says,

"I have both good and bad news for you. The angiogram shows that your 3 main coronary arteries are all severely blocked. The good news is that we caught this before you had a major heart attack."

"The bad news is that I am recommending you have triple bypass surgery as soon as possible. Your heart is working overtime, and it is just a matter of time until it gives out."

The news is shocking, but in addition to your health concerns, you also have the business deal to worry about. This deal is an opportunity to make a name for yourself, and your boss has been very vocal that he was counting on you, trusting that you'd be the one for the job. You find yourself having to weigh your work ambitions against the recommendation from Dr. Coral because if you get surgery, there is no way you'd be able to take on your current work responsibility.
 
Which of the following decisions would you be most likely to make?
 
  • I would put aside Dr. Coral's recommendation and instead take responsibility at work for the current deal. I'll wait to have surgery in about a month.
  • I would follow Dr. Coral's recommendation by having surgery immediately, even though this forfeits the current opportunity at work.

A little feedback on what you chose.

It's not that physician's don't care about your other values, but they are primarily concerned about your health, and you might not even have lived long enough to finish the business deal if you didn't have this surgery immediately. This does, however, bring up an important fact: patient's do sometimes reject their physician's medical judgment, and it can be at a great cost to their health.
 
Why should a patient be part of the decision-making process?
 
Why shouldn't Dr. Coral just tell you that you need surgery and leave no alternative? Efforts to share decision-making with patients are important because they acknowledge patients' rights to hold views, to make choices, and to take actions based on personal values and beliefs. In addition to being ethically-sound, this shared decision-making process also leads to improved patient health outcomes.
 
What can a physician do to help the patient choose surgery?
 
To answer this question, first it needs to be emphasized that in order for a patient to be able to participate in the decision-making process, the patient must be able to soundly make decisions. This sounds abstract and subjective, but it can be broken down into something a little more concrete. Decision-making capacity (DMC) is based on four guidelines:
 
The patient is able to:
 
  • understand the information about the condition and the choices available;
  • make a judgment about the information in keeping with his or her personal values and beliefs;
  • understand the potential outcomes or consequences of different choices; and
  • freely communicate his or her wishes
Based on these four elements, it is possible to see what a physician can do to help facilitate a "good" health decision. In order to make sure a patient fully understands the situation, a physician can ask him or her to state their understanding of the problem and of the treatment options. Also, a physician should use clear and unambiguous language with the patient at all times. Although a report might be quite clear from a physician's perspective, a patient might not be as clear about all the details. In the situation you were asked to imagine, Dr. Coral should tell you that you will die without this surgery and that waiting is not a safe option.
Also, there might be other factors keeping a patient from following a physician's recommendation. Again, in your hypothetical situation, your boss was putting a lot of pressure on you not to let him down. Also, this decision would potentially have an effect on your advancement at work. You might not have felt free to elect surgery even if you knew it was the only good decision for your health. By directly acknowledging and addressing a patients' concerns, physicians may facilitate a decision for the surgery.
 
In conclusion, if a physician feels that a patient is not able to fulfill one or more of the elements of DMC then his or her ability to make that decision should be brought into question and surrogate decision makers should be sought. For more serious decisions, the standards for DMC should be higher than for less important decisions or those with less significant outcome differences among the choices.
 
For more information see:

 

Edward Goldman, JD, BA

Faculty

From 1978 to 2009, Ed was head of the U-M Health System Legal Office.  In 2009 he moved into the Medical School Department of ObGyn as an Associate Professor to work full-time on issues of sexual rights and reproductive justice.  He has teaching appointments in the Medical School, the School of Public Health, the Law School, and LSA Women's Studies.  He teaches courses on the legal and ethical aspects of medicine at the Medical School, the rules of human subjects research at the School of Public Health and reproductive justice in LSA and the Law School..  In 2011, Ed went to Ghana and helpe

Research Interests: 
Last Name: 
Goldman

Bioethics Grand Rounds: Janice Firn, MSW; Andrew Shuman, MD; Christian Vercler, MD

Wed, January 27, 2016, 12:00pm
Location: 
UH Ford Amphitheater & Lobby

"Implementation of the Program in Clinical Ethics"

Janice Firn, MSW; Andrew Shuman, MD; Christian Vercler, MD

Abstract: The Program in Clinical Ethics within the Center for Bioethics and Social Sciences in Medicine represents an expansion of existing services designed to promote a culture of patient-centered excellence by developing a comprehensive set of ethics-related activities at UMHS. We will introduce and outline the projects and services available to all members of the UMHS Community.

PIHCD: Jessica Mellinger

Thu, February 11, 2016, 4:00pm
Location: 
B004E NCRC Building 16

Alcoholic liver disease represents a large and growing portion of the liver disease in the US and worldwide, and the most powerful treatment shown to improve outcomes for patients with ALD is complete abstinence from alcohol.  Unfortunately, many patients with ALD continue to drink or relapse to alcohol use, even after their diagnosis, worsening liver-related outcomes and  mortality. Jessica Mellinger will be speaking about her K award project to improve outcomes for patients with ALD by developing and testing a pilot intervention designed to increase engagement in alcohol use disorder treatment.

CBSSM Seminar: Jason Rose, PhD (Toledo)

Wed, March 09, 2016, 3:00pm to 4:00pm
Location: 
NCRC, Building 16, Room 266C

Jason Rose, PhD
Associate Professor
University of Toledo

Title: “Decisions, Decisions: The Impact of Treatment Choice on Health-Related Outcomes”

Abstract: From selecting a health care provider to choosing among an array of over-the-counter treatment options, choice has become a ubiquitous element of health care. Using an experimental, lab-based approach, the current research examines how, why, and when treatment choice impacts health-related outcomes (e.g., pain, discomfort).

 

CBSSM Seminar: Michael D. Fetters, MD, MPH, MA

Thu, April 14, 2016, 3:00pm to 4:00pm
Location: 
NCRC Building 16, Conference Rm 266C

Michael D. Fetters, M.D., M.P.H., M.A.
Professor, University of Michigan
Co-Director, Michigan Mixed Methods Research and Scholarship Program
Director, Japanese Family Health Program
Co-Editor, Journal of Mixed Methods Research

"Mixed methods research approaches for empirical medical ethics”

Abstract: Mixed methods research involves the integration of qualitative and quantitative methodology. The purpose of this presentation is to illustrate potential applications of mixed methods methodology for conducting empirical medical ethics research.

Emily Chen, MA

Research Associate

Emily Chen joined CBSSM in February 2016 and works with Drs. Julie Wright and Darin Zahuranec on several grant funded research projects on developing decision aids and family perspectives in decision making. Prior to moving to Michigan, Emily worked on several studies regarding mindfulness and cognitive styles at Harvard University. Emily received her BS in Atmospheric Science and a certificate in Neurobiology and Cognitive Science from National Taiwan University. She went on to receive her MA in Psychology from Boston University.

Last Name: 
Chen

CBSSM Seminar: Reshma Jagsi, MD, PhD

Wed, May 18, 2016, 3:00pm to 4:00pm
Location: 
NCRC, Building 16, Room 266C

Reshma Jagsi, MD, PhD
Associate Professor, Radiation Oncology

"Stewardship and Value:  Are we choosing wisely in managing breast cancer?"

Abstract: This lecture will begin with a brief discussion of the moral foundations of physicians' obligations to serve society, in addition to the patients they directly serve.  It will then consider analogies between financial stewardship and antibiotic stewardship, and it will conclude by focusing on several examples of opportunities for better physician stewardship in breast cancer, including slow uptake of short courses of breast radiation and rapid increases in the use of bilateral mastectomy for unilateral disease.

Bioethics Grand Rounds

Wed, May 25, 2016, 12:00pm
Location: 
UH Ford Amphitheater & Lobby

Kayte Spector-Bagdady, JD, MBioethics

Abstract: In 1966, Dr. Henry Beecher argued that there was no more reliable safeguard for the human research subject than an “intelligent, informed, conscientious, compassionate, responsible investigator.” Considering the current strictures of our human subjects research compliance enterprise, and wide-spread industry hand wringing over the proposed revisions to regulations, we might perhaps long for a simpler time when researchers with “high ethical purposes and completely good morals” were assumed as opposed to compelled. And yet. This presentation will explore the implications and aftermath of the STD experiments conducted by the U.S. Public Health Service in Guatemala in the 1940s.

Bioethics Grand Rounds

Wed, June 22, 2016, 12:00pm
Location: 
UH Ford Amphitheater & Lobby

Timothy Johnson, MD

"Ethical global health engagement: the Michigan Women's Health Model"

Millennial learners are experiencing and want to engage in global issues.  As institutions develop opportunities for their students, ethical issues need to be considered.  Transnational, transcultural, and translational issues as well as issues of equity, bilateral gain, economic transparency, academic values and sustainability must be factored into academic institutional partnerships between Western and low income countries.  The Ghana experience will be used to develop the concept of a “Michigan Model”.

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