When Health Goes, Doctor-Patient Relationship Should Grow

Jul. 7, 2009
Ronald M. Epstein, M.D.

The cornerstone of a good doctor-patient relationship begins with the doctor’s ability to clarify a patient’s preferences and values, especially during a difficult diagnosis, a commentary in the Journal of the American Medical Association said.

Lead author Ronald M. Epstein, M.D., of the University of Rochester Medical Center, also suggests there are certain things physicians can do or say to define each situation, including being mindful their own biases.

Before having a high-stakes discussion, he suggests doctors ask themselves questions such as: “Has the patient shown understanding of the relevant options?” “Do I understand the patient’s values?” And, “In what ways are feelings and intuitions informing or biasing preferences?”

“It is essential for physicians to find ways to be appropriately engaged with patients as they guide them through difficult decisions,” said Epstein, professor of Family Medicine, Psychiatry and Oncology at URMC and director of the Rochester Center to Improve Communication in Health Care. “Without adequate communication skills and the willingness to know their patients as people, doctors cannot deliver patient-centered care, which is the hallmark of quality.”

The JAMA article, published July 8, 2009, offers a common scenario as an illustration of things to consider during a shared deliberation between doctor and patient. Two men are diagnosed with localized prostate cancer. Each man is weighing three options: surgery, radiotherapy or watchful waiting, in the absence of compelling data favoring one approach.

Even if each patient is well-informed, however, he might have very different personal beliefs, Epstein noted. One man might fear surgery because of the belief that it could spread the cancer, whereas the other man might believe surgery is the best way to remove all of the cancer.

In these types of situations, the article said, doctors should guide patients to use their emotions and logical thinking skills in concert, and should frame information with more than one perspective. An example of a way to present complex information is: “For some people, a 10 percent risk seems like a lot -- but for others it’s small compared to the benefit.”

Patients share the responsibility to articulate their gut feelings, knowledge and values, especially in the face of uncertainty. “Patients need to go beyond comprehension to a greater depth of knowledge and the ability to apply information meaningfully to a particular situation,” the commentary noted.  

Physicians can address a patient’s conflicts by probing whether the gut feelings make sense, and to untangle emotions from long-term utility. If a patient is making a decision about a colostomy, for example, the doctor might point out that although colostomy carries a negative image, surprising data shows that most patients who live with it report a high quality of life.

If both sides work hard through complex situations, Epstein said, the resulting relationship can correct misconceptions, increase options, generate new ideas, and promote respect and learning.

Database research used as a basis for this commentary was funded by the American Board of Internal Medicine Foundation, in a grant to Epstein. Co-author Ellen Peters, Ph.D., of the University of Oregon, is funded by the National Science Foundation.

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