Uncertainty, responsibility, and the evolution of the physician/patient relationship

Abstract

The practice of evidence based medicine has changed the role of the physician from information dispenser to gatherer and analyser. Studies and controlled trials that may contain unknown errors, or uncertainties, are the primary sources for evidence based decisions in medicine. These sources may be corrupted by a number of means, such as inaccurate statistical analysis, statistical manipulation, population bias, or relevance to the patient in question. Regardless of whether any of these inaccuracies are apparent, the uncertainty of their presence in physician information should be disclosed to the patient. These uncertainties are not, however, shared by physicians with patients, and have caused a direct increase in patient responsibilities and mistrust. Only when disclosure of uncertainty becomes commonplace in medical practice will the physician/patient relationship evolve to a level of greater understanding and satisfaction for both the physician and patient.

Advances in modern medical technology and changes in patient values have inspired an evolution in the role of the physician. Breakthroughs in medicine occur on a daily basis, and for the most accurate and successful applications of new information physicians have been increasing their use of an evidence based medicine (EBM) standard of care. However, among EBM practising physicians there is a gap in both the amount and type of information that is given to patients and that which should be given. This dearth is comprised wholly of uncertainty and has caused a distinct increase in the responsibilities of the patient. The following paper will argue that physician failure to disclose uncertainty concerning standard of care has increased the responsibilities of the patient. Full disclosure, along with these new found patient responsibilities, will lead to the next level in the evolution of the physician/patient relationship, one of greater patient understanding and satisfaction.

EBM involves the physician applying the best and most up to date scientific evidence available, his experience and knowledge, and his knowledge of patient values and goals, in order to recommend a course of treatment to the patient.¹,²,³,⁴ The most prominent sources for evidence based decisions are clinical trials and studies conducted and published by other professionals.¹,³,⁴,⁵ However, the quality of the evidence provided by these sources is questionable. Errors in peer review occur; researchers can be biased; numbers are misrepresented to prove hypotheses, and the structure of the study may be misrepresentative of underlying truths concerning the results, such as characteristics of the subjects or length of the study.²,⁴,⁵,⁶ Furthermore, applicability of the study results to the actual patient in question must be ascertained. Each of these factors contributes to the underlying degree of uncertainty in the physician's diagnosis, prognosis, and recommended treatment. The existence of these uncertainties is not, however, being conveyed to the patient.

For quite some time the uncertainties involved in diagnosis, prognosis, and treatment have rarely been acknowledged in modern medicine. Though physicians are aware of the prevalence of uncertainty that underlies routine practice patterns they face each day, these components do not emerge during the informed consent process. Braddock and colleagues reported that during the informed consent process uncertainty was made clear only 5% of the time, indicating a major gap in final disclosure and the consent process.⁷

It has been argued that most physicians have been trained to accept and deal with these situations in a manner that keeps the patient uninformed about the reality of uncertainty.⁸,⁹ Modern medical schools have been slow to teach students how to deal with the communication of medical uncertainty and risk. Some are just beginning to integrate EBM into their curricula.²,¹⁰ In the past, individuals such as Jay Katz have argued that physicians are trained to display an air of confidence and ignore uncertainties, while others, such as Renee Fox, argue that physicians are trained to accept some uncertainty.⁹,¹¹ Regardless of these arguments, uncertainty of the evidence applied in diagnosis of the patient, prognosis, and treatment is not being disclosed.

Acknowledgement of medical uncertainties as standard practice does have its critics. A number of investigators argue that there are those patients who do not wish to be involved in the actual decision making process, yet others have indicated patients do wish to know as much as possible about their ailments.¹²,¹³,¹⁴,¹⁵ Most notable is the argument that admission of uncertainty will have a detrimental effect on patient trust, confidence and satisfaction, or that patients may be harmed by such revelations.¹⁶ Johnson et al found a strong correlation between physician disclosure of uncertainty and patient dissatisfaction. There is evidence, however, that the method in which uncertainty is expressed by the physician may be the deciding factor in patient satisfaction.¹⁷

It is apparent that there are positive elements in the disclosure of uncertainty. By disclosing uncertainties the physician is contributing information that may be vital to the patient's final decision. The inclusion of this knowledge makes for a more complete informed consent, which promotes the patient's values and autonomy.⁷ Furthermore, the majority of physicians can offer assistance, converse with, and address, concerns of the patient that may have been previously masked by incomplete disclosure. Studies have indicated that the way in which physicians handle uncertainty and the manner in which it is presented will have a high degree of impact on patient understanding and satisfaction. There are methods physicians can use when disclosing uncertainty, which will result in an increase in patient satisfaction and understanding.¹⁶,¹⁷,¹⁸,¹⁹,²⁰ Hewson and colleagues published a series of nine points in an attempt to facilitate the expression of uncertainty. Among them are: physicians should make it clear that they will answer all question related to the patient's health care; physicians should recommend other sources, such as valid websites; physicians should be open minded and sympathetic; physicians should explain their own biases, goals, and values, and the patient should be explicitly informed of all alternatives.²¹

Patients are coming to the realisation of the existence of these uncertainties, yet physicians are slow to acknowledge that there is a resistance to this change. By making patients aware of these uncertainties, physicians will increase their ability to communicate with them.²,¹⁶,¹⁸ The fear that admission of uncertainty will discredit the medical profession and cause more harm then good is widely felt; however, physicians need to acknowledge that this uncertainty is already at their door.⁹,¹⁶ Trends in malpractice claims, in which patients sue physicians due to negligence caused by lack of disclosure, has increased rapidly since the 1970s, causing what has been termed a “malpractice crisis”. Though claims rates have stabilised, they have yet to seriously decline.²²

Malpractice is not an unknown word to the American public, and it is fundamentally correlated to a failure on the part of the physician. According to the National Practitioners' Data Bank, from September 1990 to June of 2005, 275,592 claims were paid by practitioners. This number is limited by the fact that it only includes reported settlements and plaintiff victories. Cases found in favour of the physician, cases dismissed, or cases involving hospitals and institutions are not included; therefore, the actual number of claims made is considerably larger.²³ Another source concluded that there are more than 125,000 cases against physicians in US courts on any given day. The same source claimed that 70% of all initial malpractice claims are dismissed and do not even go to trial.²⁴ It is difficult to truly estimate the number of such claims made because of how many do not go to trial or are unreported.

Change has been rampant over the past half century; patients have demanded more of their healthcare systems and in turn have increased their own responsibilities. These improvements include greater access to health care, disclosure of information, and involvement in decision making, and have led to increased patient knowledge and responsibility. Lack of disclosure makes patients feel misled, and malpractice claims ensue.²⁰,²⁵,²⁶ On the other hand, informing patients of the possibility of uncertainty will create an acceptance of the unknown, evolve into a more informed decision making process and decrease malpractice claims, at the very least because patients will have been more informed and will not feel deceived. Professionals have estimated that over half of these claims are clearly preventable by improvements in communication or even so much as an apology.²⁰,²⁵,²⁶

Malpractice is just one element that indicates patient mistrust in physician disclosure. Patients have turned to other sources and taken more responsibility upon themselves because of evidence or fear that their physician is giving them incomplete information, resulting in an increased number of second opinions being sought and increased referencing of secondary sources.²⁷,²⁸,²⁹,³⁰ Consistent physician failure to make uncertainty known has pushed patients to accessing resources such as other professionals and specialists.³¹,³²

With respect to medical care, patient use of the internet has grown largely because of the need for, and availability of, online information. A number of studies have indicated that patients are increasingly accessing the internet for information and in some instances “second opinions” that they are not obtaining through their physician.³³,³⁴,³⁵ Physicians have also said their use of such resources is increasing and that it is benefiting patients.³⁶,³⁷,³⁸,³⁹,⁴⁰

Physician failure to disclose and the inherent misunderstanding of uncertainty on the part of patients have caused a clear increase in patient responsibility. Though disclosure of uncertainty will not decrease extra patient responsibilities, it will allow for greater communication and an advanced level of shared decision making between the physician and patient. By communicating uncertainties, physicians will be able to engage patients in a scenario that allows for greater understanding of goals, values, and thoughts. Patient understanding of uncertainties will remove prognosis fallacies, increase participation in treatment, and put less of a burden on physicians.⁹

The evolution to the next level of the physician/patient relationship is dependent on acknowledgement by both the physician and patient that medicine is fallible and that evidence contains uncertainties. The practice of EBM, and disclosing uncertainties involved in care, will allow for a relationship in which the values and goals of both the physician and the patient will be clearer to each party. Treatment, diagnosis, and patient satisfaction will improve with advanced communication. Though patient responsibility for obtaining second opinions has increased along with the use of secondary sources, such as the internet, these responsibilities will be more accepted, and physicians will adapt to their use in practice. Once physicians and patients accept medical uncertainty and patients readily assume responsibility for accessing resources beyond a single physician, the physician/patient relationship will become one of shared decision making, which promises to increase patient satisfaction and lead to a greater understanding of treatment and illness. Whether physicians like it or not, patients are beginning to understand medicine's uncertainty, and it would be best to embrace this progress rather than obstruct it.

Abbreviations

EBM - evidence based medicine