“You don’t understand!” How often has this statement expressed or unexpressed, summed up a frustrating verbal exchange? When one lives with a chronic condition such as RA, good communication becomes a necessity and your health-care team, in particular, must understand you. Dealing with arthritis can be frustrating enough, without adding communication problems.
The fundamental “building block” of patient care should be trust, based on human interaction and good communication. “Psychology 101” is not a prerequisite for understanding that poor communication is the biggest factor in failing relationships. The manner in which a physician communicates information to a patient is equally important as the information being communicated. Patients, who understand their doctors are more likely to acknowledge health problems, understand their treatment options, modify their behaviour accordingly and follow their medication schedule.
Historically, the patient/doctor relationship in the clinical realm has been framed in terms of benevolent paternalism. Until about 1960, most codes of medical ethics relied heavily on the Hippocratic tradition, framing the obligations of physicians solely in terms of promoting the welfare of the patient, while not broaching the matter of patients' rights. The past several decades have seen tectonic societal shifts that have resulted in increasing empowerment of individuals against the authority of government and institutions, creating a surge of rights-based movements, with patients' rights emerging as a societal demand alongside women's rights, minority groups' rights, consumers' rights, and others.
This dramatic shift appeared to move the locus of authority in decision making from the physician to the patient. And indeed the emergence of the Internet (Dr. Google), with its myriad health-related websites and other sources of medical information, has given many patients the impression that they can largely manage their own medical affairs, with physicians serving primarily as consultants. But the reality is more complex: the wealth of information available to patients has proved to be as dangerous as it is helpful, and today patients and physicians are beginning to find a healthier balance of power through a process of shared decision making. With this approach, physicians are seen as having expertise and authority over matters of medical science, whereas patients hold sway over questions of values or preferences.
The shared decision making process reflects a recognition of the naturalistic fallacy, the erroneous notion that one can derive ethical conclusions from scientific facts; in truth, an “ought” cannot be deduced from an “is.” Although physicians may be experts on the medical facts of a patient's condition, those facts are never sufficient to specify a course of treatment; clinical decisions must always include consideration of the values and preferences of the patient. This approach has many implications — for example, in recognizing the right of a competent adult to refuse a lifesaving blood transfusion on the basis of his or her religious beliefs, or the right of a patient to refuse mechanical ventilation for a treatable and reversible cause of respiratory failure.
Stated succinctly, today we acknowledge that competent patients have a virtually unlimited right to refuse unwanted medical care, even when physicians correctly claim that it would be medically effective and indeed even lifesaving. More important, however, is the way that the concept of shared decision making guides the many more mundane decisions that are made in clinics every day, when physicians present patients with what they see as reasonable medical options and then help them to incorporate personal values and preferences to arrive at decisions that make the most sense for them in terms of both the medical facts and their unique personal perspective and circumstances. This approach to engaging patients has other benefits as well, such as promoting their sense of self-efficacy and improving their adherence to treatment recommendations.
