Doctor's Information

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Information is power, but when it comes to illness and disease, is too much information beneficial, or detrimental?  

THE patient-doctor relationship has, since time immemorial, contributed significantly to the therapeutic process. This personal relationship, which is based on trust and confidence, has always involved communication.   

However the communication of clinical information was not central to this relationship until recent times. Our parents and even many of us have lived in awe of the health care system. The doctor’s advice and instructions about health, illness, outcome and the different interventions available were often unquestioned.   

However, it is not uncommon today for doctors to be consulted by patients who have already done a literature search in the electronic media and made a provisional diagnosis. The doctor may even be told by the patient what the diagnosis is, or what he or she wants done.  

The public is becoming better informed about health because of the explosion of health information in the print and electronic mass media coupled with the active pursuit of such information. 

 

Quality of information  

With this paradigm shift, the provision of clinical information is now an essential component in the development of the trust and confidence in a patient-doctor relationship. Consumer bodies advocate better information so that patients and their families can make better-informed decisions.   

Yet much of the information available to patients is misleading and inaccurate. The need to improve the quality of the information and to consider the individual’s information needs have been the focus of attention of health educators and planners worldwide.  

The definition of quality information varies with different individuals, and even in the same individual, at different phases of his or her life. The core requirements would include unbiased, current information about the individual’s illness, the possible and likely outcomes, the risks and benefits of different interventions and assistance in decisions about his or her treatment preference(s). There should be discussion whenever there is uncertainty.   

Individuals vary in their requirements for knowledge about their medical condition and what they want to be informed. Some cope better with uncertainty than others. Many in our society still prefer their doctors to make the decisions. The challenge is to assess and decide what the patient wants and needs.   

The desirability of providing patients with up-to-date information and the amount of such information have been questioned by both patients and doctors. Whether such information will promote or alleviate a patient’s anxiety is a pertinent question.   

Would such information increase demands for services by the small, vocal, privileged minority at the expense of the collective good in the public sector? The costs of providing quality information in the form of leaflets, videos and other audio-visuals have to be considered.   

The uncertainties and risks of medical treatment would be exposed even more by better quality information. Uncertainties and risks are certainly abundant in healthcare!  

The advocates for quality patient information, however, argue that it will enhance patient compliance and satisfaction, thereby reducing the likelihood of patient dissatisfaction. The position taken is that patients would be better equipped when forming their views about the services they need and receive. They can make informed decisions about their own healthcare and treatment. They will be more able to identify the services most suited to their needs and are more likely to be capable of accessing care and the services themselves.   

The pressures on the health system may be eased through patients’ improved understanding. The acknowledgement of the unscientific basis of many aspects of medical practice may persuade greater societal involvement in clinical trials designed to provide answers to reduce uncertainties in medical practice.  

The Internet  

An ever-increasing number of Malaysians are subscribing to the Internet, However, there is no accountability for the quality and safety of the information on the Worldwide Web. Anyone with a computer and a modem can be an author, publisher and editor simultaneously, and worse still, can do so anonymously.   

A search on the Internet for any medical condition will reveal information of variable quality. This is not surprising when scientists have the same access to the Web as those with commercial or other agendas. While there are calls for regulation of health sites on the Web, it will be quite some time before this can be implemented.   

Clinical situations  

Society expects and permits an ill person to adopt a certain role that is not expected of someone who is healthy. An ill person is vulnerable and dependent on others – these may be doctors, nurses, other healthcare professionals, family members and/or friends.   

Individual autonomy can be a heavy load for many to bear. Making a decision on treatment may already be sufficiently difficult.   

There has been much emphasis on choice in medical care. Many people have the perception that there is a large menu akin to consumer goods and services like food and clothing. The reality is that the choices in medical treatment are limited. For example, cancers can be treated with surgery, radiotherapy, chemotherapy or a combination of these treatment methods.  

In the typical clinical situation, diagnosis is followed by information about the prospects of what may occur and the treatment available. The treatment choice for patients is a very small menu. It is not uncommon to find only one item on the menu, for example, a certain antibiotic for a particular bacterial infection.   

Sometimes, the patient may also find himself or herself in a worse situation. There is nothing on the menu – for example, untreatable conditions like Alzheimer’s disease, inoperable cancer.   

The relationship between patients and doctor, in earlier times, was a direct one-to-one relationship.  

However, the situation today is different in many instances, particularly in healthcare institutions like hospitals, in which, the relationships are between patients and complex organisations staffed by many professionals.   

The traditional patient-doctor relationship is being replaced by multiple relationships between the patient and doctors, nurses and other healthcare professionals, all with different perspectives of the patient’s problem(s). It is no wonder then that some sociologists are coming to the view that the patient-doctor relationship is becoming obsolete, particularly in healthcare institutions like hospitals.   

When the well meaning family member(s) and friend(s) is added to the equation, the situation can become more complicated. Sometimes, even community leaders and politicians get involved.   

Most doctors who have been in practice for some time have encountered situations when they had difficulty working out who is the real decision maker – the patient, family member(s), friend(s), local community leader(s) or politician(s)!   

Basing a decision on ...  

The basis on which clinical decisions are made is usually not discernible to the layperson who has no formal training in Medicine. Studies have been carried out on patients’ understanding of the information provided to them by doctors and other healthcare professionals. The results of these studies reveal a stark fact – that although society has unprecedented access to health information, it lacked the skills to interpret them.   

The situation is compounded further, in our country, by a multi-racial and multi-religious population that has different perspectives on health and illness. There are differences in beliefs, knowledge, costs, resources and capabilities.   

The situation is also not helped by the numerous patients that doctors in a busy practice have to manage. Many doctors, in a 5 to 10 minute consultation, have to take a history, perform a physical examination, make a diagnosis and provide information – a truly challenging task indeed, especially when it has to be repeated umpteen times in a day!  

The law  

Court decisions have also impacted on clinical situations. For example, in Burke vs General Medical Council, the English High Court’s ruling in 2004 enabled a patient to insist on treatment, in certain circumstances, although it was against the doctor’s judgement.   

However, balance was restored when the Court of Appeal overturned the judgement in 2005. It ruled that if a doctor decided that a certain treatment is not clinically indicated, he or she is under no legal obligation to provide it, although the doctor should offer a second opinion.   

Similarly, Malaysian court decisions have impacted upon and continue to impact upon medical practice, as do the various regulations.  

The medical profession’s role 

The medical profession recognises its responsibility to provide quality information and the need to work with patients to use the information to the patients’ best advantage. After all, no one disputes that better patient-doctor relationships will enhance the image of the healthcare professions and the healthcare system itself. 

No doctor would want anything to happen that could lead to an erosion in the public’s trust and confidence in the health system, in general, and the patient-doctor relationship, in particular, irrespective of who is responsible.   

Although many patients prefer a passive role, it is important to promote a positive attitude towards their involvement in the decisions made, particularly in primary care, in which the patients could involve themselves to a greater extent than they currently are.  

There has been much emphasis on communication skills in medical schools worldwide. This will go some way towards addressing the need for better communication between patients and doctors. But more needs to be done for information provision. This requires an expenditure of time and effort; communication is never one-way traffic.  

The patient’s role  

The patient has a crucial role to play in making full use of the information available about the medical condition that he or she has.   

One should ensure that the doctor provides information about some or all of the following, where applicable: 

·        What is the diagnosis and the possible complications of the condition? 

·         What treatment is recommended and why? 

·         Details about the proposed treatment, its potential side effects or complications. 

·         What is the success rate of the proposed treatment? 

·         What alternative treatments are available, their potential side effects or complications and success rates? 

·         What could happen if one chooses not to have any treatment? 

·         If surgery is proposed, who is going to perform it and what is the extent of the experience of the surgeon?  

·         If anaesthesia is to be administered, who is the anaesthetist and his/her experience? 

·         If admission to a healthcare institution, for example, hospital, day surgery centre, hospice is recommended, then you need information about the institution, its facilities and equipment, its nursing and other staffing, its risk management procedures and the charges in the case of private institution.   

Any doubt should be clarified with the doctor. In addition, one should always inform the doctor of one’s preferences, fears and anxieties.   

This is often easier said than done, particularly for the large segment of the population who do not have a regular doctor.   

This is why the medical profession has always recommended that every one should have a regular doctor.  

Relationships require time and effort for its development. The patient-doctor relationship is no different. If one has a regular doctor, then he or she can assist in the communication of fears and anxieties to the specialist. Remember, doctors cannot read minds.  

In considering the statistics provided, one should always remember that they are like swimwear. What is revealed is suggestive, but what is concealed is just as important, if not, vital.  

If the doctor does not provide the information sought, one should consider seeking opinion(s) from another doctor(s) or changing one’s doctor.  

Conclusions  

Good communication between patients and doctors will always have a positive impact on a therapeutic relationship.  

Not only the medical profession and patients have important respective roles to play. Society also has a crucial responsibility to ensure that heavy burdens are not placed on the patient-doctor relationship.  

Well-intended regulations or rulings may be impractical because of the various considerations discussed above. This can lead to a negative impact on the provision of healthcare, which is not in anyone’s interest at all.  

(Written by Dr Milton Lum)