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Saturday, December 1, 2012

Whose body is it, anyway?

A study reported recently in the Journal of the American Medical Association found that three strategies for regulating long term asthma medications produced similar results.  One of these involved symptom diaries, while a second used sophisticated nitric oxide exhalation testing.  The researchers found that neither produced better results than a third strategy, which was simply to suggest that patients regulate their own medications based on symptoms.  

Two things struck me about this study.  One was that simple solutions turn out to be best more often than we may expect.  The second was what the authors said about their findings:

“The data from the study are reassuring that we’re doing no harm in allowing this flexibility.”

Allowing this flexibility?  First, I hope these academics know that patients regulate their own medications - for asthma and a host of other conditions - with or without permission.  Second, and more fundamentally, this inadvertent expression of paternalistic medicine sounds weirdly out of synch with the contemporary movement toward collaboration between care providers, families and patients.  After all, the person with a chronic disease will only enjoy the best possible health if she becomes as expert in her own care as her physicians.  Or more so.

Which is not to say that I favor the practice of laying out a smorgasbord of choices for those who come to us for care.  (Back pain?  Tell me what you'd like - an X-ray?  An MRI?  Referral to a chiropractor?  How about a nice spine surgeon?)  While this latter approach, which has become common in some quarters, seems to empower the patient and support her autonomy, it deprives the person seeking care of what is most helpful, and that is the thoughtful and informed opinion of the physician.  

But some raise an objection here.  Bioethicist Robert Veatch has suggested that since literally every medical decision is value-laden, and for the most part physicians do not and cannot understand their patient's values, it is impossible even in principle for the physician to make medical judgments in the "best interest" of the patient.   One treatment carries more side effects but the alternative costs so much that I'd need to sell my house.  What textbook tells my doctor which one is "right for me"?

When I pick a primary care physician to supervise my health I want him to have the right knowledge, skill set and dedication to do a really good job.  I'll also want to make sure that he's flexible enough to work with me when I need to call the shots,  but confident enough to tell me what he thinks is best.  It's a tall order.

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