Until the 21st century, physicians were perceived as diligent, dedicated, hardworking, knowledgeable professionals whose opinions were valued and whose judgment and advice was highly regarded. When given choices for their individual care, patients, who were either medically uninformed or unsophisticated, would defer a decision to their physician. They would ask the doctor, “What would you do.” or “What would you recommend?” This paternalistic model was the basis of the doctor-patient relationship.
The concept of Paternalism in this context is defined as the physician managing and directing the patient’s healthcare decisions. The patient follows the doctor’s suggestions and trusts he is doing what’s best for him. The doctor is the parent directing his child (the patient) to follow advice. When faced with the situation of what to do next, or where to go from here, the patient defers decision-making to the guidance and recommendation of the doctor, just as a child would to his parent. The patient surrenders his will to the discretion of the physician. The patient is concerned for himself, but he lets the doctor be in charge of health care decisions.
The paternalistic attitude has been assigned to ancient history, however. An essay in a recent issue of JAMA (Journal of the American Medical Association) addresses paternalism and contrasts it to today’s “shared decision-making” concept. In today’s doctor-patient relationship, the patient has presented a list of medical options from which he is expected to make a decision regarding his care. This is difficult, even for medically sophisticated people. Patients with extensive medical knowledge can fit into this model, but the “average joe patient” finds this very confusing. He wants to be informed enough to make the right choice, but he lacks the education and expertise needed to do so.
The emphasis on shared decision-making places the onus back on the patient and/or his family. Without professional guidance patients probably are unable to make the wisest decision on their own. Patients want our professional opinion. They want a relationship with their physician, and they see the physician as their health care advocate. Patients want their doctor to “have some skin in the game.”
The essay author’s mother was quoted as saying, “Why don’t doctors tell patients what to do anymore?… How should I know if I really need that procedure or not?… What’s wrong with paternalism?”
I think some patients—probably the majority, actually—want their doctor to share their options, but also be prepared to give the patient an unbiased answer to the question “What would you do, doctor?” Human nature being what it is, people want to follow a leader. Providing “patient-centered care” means the patient, not the physician, is the central focus and the one in charge of decision-making. But just like one might ask a parent for advice, the physician is the best person to involve in your health care decisions. You’re far less likely to choose the wrong option in that case.
I think the course patients follow is largely due to the attitude of the physician. The impartial, stern, dogmatic, non-judgmental physician model is the way of today. Physicians are taught to be indifferent. Some, however, reject that model and prefer to be kind, thoughtful, and polite instead, and work alongside the patient. Sharing the decision-making, and having a well-informed patient because of physician input is the best approach. I would much prefer to be attended by the latter physician. I know that I would feel more comfortable and well-cared for as a result.
Reference: Mannix R. What Would You Do, Doctor? JAMA 2020 May 5;323(17):1679-1679.
