Treatment Choices

Changes in Consultation Style

In the paternalistic (“Doctor knows best”) form of healthcare, relatively widespread until the end of the 20th century, the doctor was consulted for treatment advice, and the patient was expected to follow the advice more or less unquestioningly. Sometimes, the treatment was even performed on the patient without discussion; often there was little by way of information or explanation for a treatment regime. Patients who did not follow advice (and there were, of course, many) were deemed noncompliant.

In the past few decades, the conduct of the consultation and the relationship between patient and doctor have changed from the paternalistic model to a more equal style of consultation, sometimes termed mutualistic. In this model, the doctor may be seen as an expert in the diagnosis and treatment of the condition; but the patient has a unique experience of the disease, as well as preferences and values that may affect the choice of treatment. Patients' expectations, influenced in part by a more consumerist and less deferential attitude to the medical profession, have combined with changes in clinical training to promote a more balanced encounter between patients and professionals. Instead of talking about compliance with doctors' orders, or even adherence to treatment plans, concordance between patients and doctors has become the aim.

Rationale for Patient Involvement in Treatment Choices

When someone is diagnosed with an illness, he or she wants to hear that there is a remedy, that it has minimal adverse effects, and that there is agreement in the medical profession that this is the best course of action. Of course, where many conditions are concerned, the patient may find out that almost the opposite is true: A definitive cure is still being sought; the adverse effects are off-putting; and specialists in the field have different ideas about the best form of treatment, leading to variation between, or even within, different treatment centers. This can be (at the very least) disappointing and confusing for the patient.

When the outcomes of treatment are more than usually uncertain, the treatment choice may rest heavily on the patient's own priorities and the patient's attitude to the limitations and adverse effects that are associated with the different treatments. In such situations, the outcome that is best for the patient is only likely to be achieved if he or she is involved in making the choice. For example, a surgeon cannot detect through clinical examination whether a woman would prefer a lumpectomy or mastectomy for breast cancer. Surgeons expected that women would prefer conservative treatment, yet when women were given the opportunity to make the choice, many surgeons were surprised how often women chose to have a mastectomy. Among the reasons that affected these women's choice were the belief that if the whole breast is removed, there must be less chance of recurrence. For some women, the fear of recurrence is, quite understandably, greater than the desire to conserve their breast.

...