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Entries in informed decision making (3)

Tuesday
May292018

Mammograms of questionable benefit.

The Harvard Medical School published this video as part of their blog describing the overuse and misuse of mammography. The blog states:

They [JAMA Insights article co-authors Keating and Pace*] further point out that the USPSTF [U.S. Preventive Services Task Force] reiterated its recommendation in 2016 and that the American Cancer Society joined the task force in 2015 in advocating less routine use of mammography and a more individualized approach to screening.

 

“One of the greatest harms is overdiagnosis, which can subject some women to harmful treatment without any benefit,” Pace said. “Additionally, high rates of false positives and unnecessary biopsies should be considered as likely outcomes of breast cancer screening.”

Personally, I use thermography. It, too, is criticized as producing too many false positives but it doesn't expose patients to radiation so they can be done frequently and checked against a baseline. Those false positives, in my mind, are Qi Stagnation or Blood Stasis and can be treated with massage and acupuncture.

It baffles me that they end by saying that doctors know best. What physician has the time to spend counseling a patient or has the skill to do it?

 

*Nancy Keating is a professor of health care policy at Harvard Medical School and a physician at Brigham and Women’s Hospital, and Lydia Pace is HMS assistant professor of medicine and an internist at Brigham and Women’s

 

Monday
Oct012012

Informed consent?

We have all lamented over the sad state of affairs in terms of our health care and informed consent. Most often we are not given a full disclosure of our treatment options. This may be because the practitioner doesn't know of other options, doesn't "believe" in the other options (paternalism) or doesn't offer the other options at that facility and they don't want to send business away. Sometimes, informed consent amounts to strong-arming. A friend of mine, recently diagnosed with stage 1 endometrial cancer, asked about her treatment options and she was told, "Surgery. Or you die." (She opted to not have the surgery. She pursued other treatments and six months later she is cancer free, with her hormones intact.) Another friend was fired from her nursing position at a community clinic for spending time with patients getting informed consent. She had been warned twice to "just get signatures".

Informed consent, with all of its supposed good intentions, is paternalistic. It tells the patient, "Here's what you need to know and here's what you need to agree to." The decision making about what was important to communicate and how that communication proceeds was already selected by the practitioner, or the State, or the facility or, most likely, all of the above. The patient just has to listen to it and agree. Sign right here. It's paternalistic and it streamlines patients into ready-made treatment options approved by the powers that be. People who are adamant about licensing and standard of practice are prone to this type of arrangement. Within this paradigm, the patient is the responsibility of the practitioner, the State and the facility. Lawsuits are the remedy of failures of this system and practitioners and facilities organize and operate accordingly. I argue that this is one of the dynamics that has caused our health care crisis.

Informed decision making, on the other hand, is a different process altogether. It allows for communication and healing to be a process in which the patient must take part. The patient must give thought to what is important to her and take action in navigating her decision making. Passivity is not encouraged, relationships are valued over paperwork or mandates and people are truly allowed to make decisions, even decisions that are not popular with the dominant culture (yes, medicine is a culture), yet still be supported. People who are adamant about choice and evidence-based practices prefer this arrangement. Within this paradigm, the practitioner and the facility are the responsibility of the patient and the State is mostly left out of the arrangement. Consumer voting (ie: finding a different practitioner) or mediation are the strategies of dealing with disappointment.

Most people concur that the latter paradigm is superior for managing intimate/marital relationships, parenting and education. But many fail to understand that choosing how one treats one's body through one's health care decisions is as personal as deciding what you eat, who/how you love and how you parent. Only in taking back our responsibility as patients can we reclaim our power and own our bodies; this is critiical in rehabilitating our health care system.

 

Wednesday
May232012

If Health Care were like AirLines

I've been meaning to recommend this website devoted to Participatory Medicine for some time now.  It's a growing movement of consumers and practitioners striving to change the face of health care by transforming the way patients interact with their health care providers.  It encourages transparency, consumer responsibility, consumer choice, informed decision-making (as opposed to informed choice), and restructuring of a broken system.  Also, check out their video, "If Air Travel Worked Like Health Care".  It's funny, yet sad.  Many interesting and thought-provoking articles to peruse.  Have at it!