Authoritarian Physicians And Patients’ Fear Of Being Labeled ‘Difficult’ Among Key Obstacles To Shared Decision Making

TLDR: It is argued that physicians may not be aware of a need to create a safe environment for open communication to facilitate shared decision making and that Rigorous measures of patient engagement, and of the degree to which health care decisions truly reflect patient preferences, are needed to advance shared decisionMaking in clinical practice.

Abstract: Relatively little is known about why some patients are reluctant to engage in a collaborative discussion with physicians about their choices in health care. To explore this issue further, we conducted six focus-group sessions with forty-eight people in the San Francisco Bay Area. In the focus groups, we found that participants voiced a strong desire to engage in shared decision making about treatment options with their physicians. However, several obstacles inhibit those discussions. These include the fact that even relatively affluent and well-educated patients feel compelled to conform to socially sanctioned roles and defer to physicians during clinical consultations; that physicians can be authoritarian; and that the fear of being categorized as "difficult" prevents patients from participating more fully in their own health care. We argue that physicians may not be aware of a need to create a safe environment for open communication to facilitate shared decision making. Rigorous measures of patient engagement, and of the degree to which health care decisions truly reflect patient preferences, are needed to advance shared decision making in clinical practice.

Full text

How To Deal With Institutional Barriers
• Precivil Carrera, Assistant Professor
University of Twente
The findings of this study underscore several issues in various fronts. For the US observer,
they raise the question of the extent, if not the validity, of consumer sovereignty where health
care is consumer- driven. For the health law practitioner, they challenge the conception of the
patient-doctor relationship as one based on trust.[1] For the practitioner, they take
professionals and those in training to task on the nature of and the sine qua non of medicine.
For the patient, they lay bare the inertia that seems to stick despite the spread of health
information and moves to empower patients.[2] Considering the socioeconomic background
of the participants, one would expect activated patients who would claim their right to have a
say in their treatment. Yet we find patients who are just as wary of how they conduct
themselves when in the consultation room.
The research of Dominick Frosch and colleagues on shared decision making highlights the
lingering institutional challenges of engaging the patient as a partner in medical decision
making. The challenges range from the structure of the health care system -- not in terms of
just financing but also delivery -- to the attitudes, nay beliefs of stakeholders, physicians and
patients alike.[3] As noted, paying more for consultation, since consultation time in the US as
in Germany is meanly reimbursed, may improve the length of the consult and is likely to
make headway in improving the quality of the interaction. Challenging institutions about what
makes a difficult patient and the paternalistic doctor as authoritative arguably needs more
attention and work.
References:
1 Portmann J. Like marriage, without the romance. J Med Ethics 2000 Jun;26(3):194-7.
2 Bridges J, Loukanova S and Carrera P. Empowerment and health care. In International
Encyclopedia of Public Health 2008, K. Heggenhougen and S. Quah (Eds.), pp.17-28. San
Diego, USA: Academic Press.
3 Lunt N and Carrera P. Medical tourism: Assessing the evidence on treatment abroad.
Maturitas 2010, 66: 27-32.

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The findings of this study underscore several issues in various fronts. Considering the socioeconomic background of the participants, one would expect activated patients who would claim their right to have a say in their treatment. Yet the authors find patients who are just as wary of how they conduct themselves when in the consultation room.