Saturday, February 13, 2016
Being Mortal (17 Feb)
Using the doctor-patient relationship models from Beauchamp & Childress reading for this week, analyze Being Mortal (book from last week). Where do you see that health professionals could do a better job helping patients? And by "better" take Gawande's lead to define it as following more what gives meaning and value to the patient's life, not what is easier for staff or makes family feel that the patient is safe.
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Childress and Siegler examine five models, or metaphors, for the physician-patient relationship: (1) paternalism (the physician as caring parent, the patient as child); (2) partnership (both parties as collaborating in pursuit of the shared goal of the patient’s health); (3) contract (physician and patient as related to each other by specific contracts, detailing their obligations and rights); (4) friendships (physician and patient as intimately related due to the highly personal nature of health); and (5)technical assistance (the physician as technician, the patient as customer) (Degrazia, 2011).
ReplyDeleteThe doctor-patient relationship historically has been seen more as the first metaphor Childress and Siegler examine: paternalistic. Physicians were almost always men of substance that assumed the role of the father figure when dealing with patients. They had a caring hand yet a firm one. Father knows best was the unwritten rule and patients trusted the physician and did whatever he told them to. A large problem in early medicine was what Dr. Gawande described as “the purpose of medical schooling was to teach how to save lives, not how to tend to their demise” (Gawande, p. 1). The physician could seamlessly spout out all the risks, potential difficulties and benefits of a procedure or treatment, but they have a hard time discussing the “what if” the procedure failed and they were left with no options. More conversations about what patients want for the end of their life need to be had. These should not only be between the patient and the physician, but also with the family, so there is no misunderstanding.
Surveys have found that patient’s top concerns include avoiding suffering, strengthening relationships with family and friends, being mentally aware, not being a burden on others, and achieving a sense that their life is complete (Gawande, p. 155). If more doctor-patient relationships were more like the partnership model where both parties as collaborating in pursuit of the shared goal of the patient’s health, we could respond to these concerns. Palliative care may need to discussed sooner when a patient is diagnosed instead of when all else fails and they have been put through harsh medical treatments and procedures.
Brand-Ballard, J., Degrazia, D., Mappes, T. (2011). Biomedical Ethics 7th ed. New York, NY. MCGraw Hill.
Gawande, Atul.(2014). Being Moral. New York, NY. Metropolitan Books
Very good analysis Jocelyn! I like your points on the paternal model. I agree, physician's don't always discuss the "what if's" with patients. They tend to just focus on the task at hand and rarely take it a few steps further to discuss the options if the procedure fails.
DeleteJocelyn, I agree that if more doctor patient relationships were more like the partnership model, that the elderly patient would feel happier and likely end up more healthy, by his own standards, than if every ailment is medically treated. Granting a person respect and exploring their goals, will ultimately end more positively for the patient's over all health.
Deletegreat recap! In my experience in the ER the physicians tend to sugar coat things or not be bold in their diagnosis to avoid difficult conversations. My favorite is when a physician gives a patient false hope that they are still in fact pregnant when we KNOW that there HCG is going down and not up. there is definitely not a partnership model being displayed here.
DeleteJocelyn I agree if our patients played a more active role in their care and it was a true partnership those patients would probably be more healthy.
DeleteAfter reading the doctor-patient relationship models from Beauchamp and Childress as well as the book Being Mortal, I think it’s safe to say that Dr. Gawande has a great grasp on what an ideal relationship between a doctor and patient should be like. Beauchamp and Childress examine five models of relationships which include paternalism, partnership, contract, friendship, and technical assistance. According to the model of paternal, where the metaphor of a “parent – child” relationship is used to describe this model, the physician in a sense acts as the patient’s “parent”. The physician is considered to have the authority related to healthcare decisions because his competence, skills and ability puts him in a position of power. The problem with this model in relation to Dr. Gawande’s ideas is that this model tends to concentrate on the physicians discretion verses respect for the patient’s autonomy or self-determination. (DeGrazia, Mappes, Brand-Ballard, pg. 74-75, 2011) Dr. Gawande argues that quality of life is the desired goal for patients and families. If the physician is taking on the role of being the “parent” then the likelihood of the patient’s true wants may be overlooked or disregarded if the physician does not agree.
ReplyDeleteIn the second model, partnership, a collaborative effort is made between the physician and patient as well as all health care professionals to achieve the desired health outcome. In this model the physician helps the patient to help himself, while the patient uses expert help to realize the ends. (DeGrazia, Mappes, Brand-Ballard, pg. 76, 2011) While I do feel like Dr. Gawande would prefer this relationship over paternal, I still do not see it as being ideal in his mind. The metaphor given is as an “adult-adult” relationship. It states that parties, physician and patient, will gain satisfaction with the results. I don’t feel like in this type of relationship, the physician could truly know or understand what his patient wants on a more personal level. The example the textbook gives is cases of chronic disease. Take for example, a physician can continue to keep prescribing and administering steroids to a COPD patient because it does temporarily fix the problem, but maybe the side effects of the steroids are doing more harm than good in this case.
The third model of rational contractors appears to be the most un-personable of them all. While I guess it does protect both parties and would ensure that a certain standard of care is given and received, this model would likely neglect the virtues of benevolence, care, and compassion. (DeGrazia, Mappes, Brand-Ballard, pg. 76-77, 2011). That goes against Dr. Gawande’s ideas of pursuing what is truly best for this patient in the end, how can this patient achieve the absolute best quality of life if they view their health care needs differently than what the contract states.
The model of friendship appears to be the most ideal and consistent with Dr. Gawande’s ideas. The text states that in a friendship, one person assumes the interests of another. In this type of model, benevolence, care and respect are achieved, however, the valid point of patients paying professionals for their personal care and because patients do not have reciprocal loyalties makes me question the genuineness in this type of relationship.
Lastly is the technician model, which seems to be the vaguest in my opinion. The textbook states that this type of model “does not appear to be possible or even desirable.” (DeGrazia, Mappes, Brand-Ballard, pg. 77, 2011). I could only assume that Dr. Gawande would not see a benefit to this type of relationship model.
DeGrazia, D., Mappes, T. A., & Brand-Ballard, J. (2011). Biomedical ethics. New York: McGraw-Hill Higher Education. pg. 74-82
Gawande, A. (2014). Being mortal: Medicine and what matters in the end. New, York, NY: Metropolitan Books Henry Holt and Company, LLC.
I agree the technician model does seem vague. It is easier to recognize what the technician model is when you work with them every day in the OR. As far as it not being desirable I think you are right patients don't enjoy their bedside manner as much but they do enjoy the results.
DeleteGreat way to describe all the roles. I feel like at some point we as healthcare professionals assume each one of these roles based on the situation we are faced with. For instance if you have a young patient come in in labor you have to feel them out to know the best way to deal with them. Sometimes a more firm parental role is needed, and sometimes the friendship model works best. For normal labor patients I feel like we display the second model, collaborating with our patients to achieve the goal, a happy healthy mom and baby. So I'm not sure if we can ever say only one model will ALWAYS work, I believe it depends on the situation at hand.
ReplyDeleteBeauchamp and Childress' "Principles of Biomedical Ethics" discusses four principles for ethical decision-making; autonomy, beneficence, non-maleficence, and justice. When looking at these principles in conjunction with the Childress and Siegler model of Doctor-Patient Relationships and their Implication for Autonomy, the first model or metaphor; Paternalism, conflicts with the principle of autonomy. In response to Case 5 (p. 709), the paternalism model represents the physician as parent and the patient as a child. His autonomy is stripped away at this juncture and the patient is at the mercy of his worried children and power-wielding physician.
ReplyDeleteGawande's book 'Being Mortal' discusses many stories such as these that have thrust the aging patient into a form of depression; another diagnosis forced upon him to add to the other diagnosis of aging. Components such as these seen in the medical world as treatable - not just acceptable. The elder patient's condition will decline, because that's what naturally happens to humans. Gawande states "This experiment of making mortality a medical experience is just decades old. It is young. and the evidence is it is failing". (p. 9). I agree with what he conveys in this eye-opening book. A person who remains in charge of their own life is happier, healthier and more content over all. Isn't that just as important if not more than whether we (the medical profession) fix every failing component of the aging body?
The story in Case 5 is very sad indeed. I completely understand the children s' idea to keep him safe from his own waxing and waning dementia. But, I feel that getting to that place is more of a process, a journey. You must find a middle ground first and take these steps along the way. To increase help for him while at home if any way possible, or other increased assistance. This will also help the patient to transition more gently into his surroundings as his path moves toward dependence.
Brand-Ballard, J., Degrazia, D., Mappes, T. (2011). Biomedical Ethics 7th ed. New York, NY. MCGraw Hill. (p. 74,709).
Gawande, Atul.(2014). Being Moral. New York, NY. Metropolitan Books
(p.9).
I love that the point of elderly people getting autonomy and decision making is being addressed. It has to be depressing to know that the years you have left are coming to an end. I have a gym client that just turned 65 and she really struggles with it. I can only imagine how she would feel if she could no longer come to the gym 5 days a week or carry on about her day in her own way.
DeleteI think aging is scary for everyone. We see what the disease process can due to the older population. When the mind starts to fade and others want to step in but you don't agree with them. Reminds of the show ER when Alan Alda played a physician who was beginning to have dementia. When it was discovered he told the other physician he wanted to kill himself. He said he was not ready yet but what if he waits too long and lives the rest of his life confused and alone. The fear is real for our aging clients who have had CVA's of MI's and are no longer able to do for themselves. When do we ethically step in?
DeleteAs I read Being Mortal, I watched the evolution of Gawande through various doctor-patient relationship models as he took on the models listed or gave us examples of observing others as they took on the doctor-patient relationship models. The progression through the models shows that health professionals could do a better job helping patients by listening to them, helping them to be autonomous in their disease process, and helping them achieve the goals they have for themselves during their illness.
ReplyDeleteThe paternal model of doctor patient relationship can be one of two types: the parent -infant type where only the doctor is autonomous and the parent-adolescent type where the doctor guides an obedient patient deemed not competent enough, but has the ability to understand what the doctor advises. We see Dr. Gawande in this role in many of his early cases, especially that of Sara Monopoli, where he took on the attitude “I’m going to fix this.” He advised them and led them toward the experimental procedures, never once asking them, especially as he knew the end neared, what they wanted to accomplish during this stage of their illness. He focused very much on care and what he felt her needs were instead of focusing on respect, her rights and autonomy. He concedes, “discussing a fantasy was easier- less emotional, less explosive, less prone to misunderstanding- than discussing what was happening before my eyes” (Gawande, p.169). However, in the Frontline interview, Rich points out how excruciating those remaining months were. As Sara underwent the therapy advised, she became too weak and ill to even hold her baby. Rich states they lost valuable time that they could have had as quality family time to do all the things they needed to enjoy each other and become emotionally ready for the inevitable.
In trying to fix his “paternalism” approach, Gawande moved into the rational contractor model with the next example patient. This was another form of what he often referred to as when he was being the “informative doctor”. On page 200, he notes this is the opposite of the paternalistic relationship. In this model, doctor and patient are autonomous but there is no presumption of a shared goal, they agree to exchange goods and services in a very business feeling manner. Trust is not presupposed and emphasis is on the patient's rights and the doctor's responsibility.
This patient was found to have metastatic colon cancer. Gawande removed a large section of cancerous mass from her colon but was not able to get it all because of how much it had already spread. When he was speaking to her after the procedure, he found himself explaining to her the details of the surgery and her impending recovery, “everything except how much cancer there was. But then I remembered how timid I had been with Sara Monopoli…. So when she asked me to tell her more about the cancer, I explained that it had spread not only to her ovaries but also to her lymph nodes. I said that it had not been possible to remove all the disease” (Gawande, p. 181). A few days later he tried again, in not wanting to be paternal, he told her there was not a cure and shared the goal was to prolong her life. In following her the months and years since she shared with him that his approach had been very blunt and harsh, and she had felt he dropped her off a cliff.
We see the use of the friendship model as he works through his father’s illness with him. With this model, there is a relationship, an emotional attachment invested in the case health wise, but also as the patient as a human being/ a friend/ a family member. Within this model, doctor and patient are autonomous but work together towards a shared goal of the patient's health. Accompanying him and his mother on visits in Cleveland, and being present during treatment, as well as the end. It’s actually his observation during the on-taking of this role that he learned to achieve the next role, his doctor-patient relationship “graduation” role.
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DeleteAfter watching mentors his role models working with his father, Gawande’s ultimate goal was to achieve the partnership model with his patients, where the doctor and the patient work together, and both autonomous. They share a goal of the patient’s health and autonomy, fueled by collaboration and trust. He achieved this with his patient Jewell Douglas. His first consult with Jewell coincided with his father’s visits with Dr. Benzel. Through Dr. Benzel’s interactions with his father, Dr. Gawande had learned how to look at, listen to and counsel people in a way that was less alarming, yet still let them know there was concern, and the seriousness of the situation. He learned by being an interpretive doctor that it was his role to help the patients determine what they wanted. “Interpretive doctors ask, ‘What is most important to you? What are your worries?’ Then, when they know your answers they tell you about the red pill and the blue pill and which one would most help you achieve your priorities” (Gawande, p. 201). Throughout many bouts with her disease, he was able to consistently ask Jewell what was important to her, and what her goals were. He even managed to steer himself from a spontaneous paternal decision during a surgery where he could not make the difference he wanted without violating Jewell’s wishes. “As we tried to chip it free it became evident that we were risking creating holes we’d never be able to repair. Leakage inside the abdomen would be a calamity. So we stopped. Her aims for us were clear. No risky chances” (Gawande, p. 241). He then inserted drainage tubes to relieve her symptoms, and closed her incision. When she awakened he told her he could not complete the surgery to allow her to eat again. Three days after surgery, she went home with hospice. He went to visit a few days after. She’d had family visiting all day, and verbalized she was thankful for the tubes relieving her pain. They talked about good memories from her life and the peace she had made with God. Gawande then affirmed the long process he had undergone: “I left feeling that, at least this once, we’d learned to do it right. Douglas’s story was not ending the way she ever envisioned, but it was nonetheless ending with her being able to make the choices that meant the most to her” (Gawande, p. 242). Two weeks later he received a note from her daughter telling him that Jewell Douglas had passed in a peaceful, perfect ending. Gawande had come full circle in the evolution of his doctor- patient relationships.
In the technician model, doctor and the patient are autonomous but the patients are "consumers" receiving “technical services" provided by the doctors. There is an abdication of moral authority in this model. The best example I can apply to this from his book is when his father went to Cleveland for new radiation techniques. “Unlike Benzel, the specialists had not been ready to acknowledge how much more uncertain the likelihood of benefit was. Nor had they been ready to take the time to understand my father and what the experience of radiation would be like for him” (Gawande, p.216). They made molds for his body, they set the position, the radiation doses. It was all a very cold, technical, and especially unpleasant, experience. The values in his father’s health and disease, and the medicine needed to treat him had been obscured by the technicalities.
Gawande, Atul. (2014). Being Moral. New York, NY. Metropolitan Books
1. Paternal 2. Partnership 3. Contract 4. Friendship 5. Technician These are the 5 Models or metaphors for doctor patient relationship.
ReplyDeleteI am mainly going to focus on the model of technician. The main reason I am focusing on this is because this is the model I come in most contact with everyday. Working in the OR our doctors a very well trained technicians. I find that the majority of them don't enjoy a lot of patient interaction most of them don't like going to their office to see patients they enjoy spending time in the OR. They see patients as consumers and they want to deliver a service ie (taking out an appendix) Like a lot of other doctors they take a good amount of pride in their work. In the same way surgeons are technicians so are the nurses and techs that work with them. Our doctors will admit that they are as only as good as the help that we provide them so as OR nurses we have a very high level of training as well. When all of this happens it ends in great results for our patients.
IO feel the same in the ED when we have a full arrest. We are technicians for the patients and do as we were trained. We hopefully stabilize them and we then send them to ICU and never see the patient again. We were completely technical in our role. We at no time will have a relationship with the patient. I like the relationships we develop with our patients. I think it would be hard for me to work full time in a technical role only.
DeleteI agree with you Chris. I'm in the same role sometimes with my non-responsive hospice patients. I'm a technician providing comfort care and administering medication. I don't think I could be in that role all of the time. I truly enjoy the interaction I get with the alert and oriented patients. I like the relationships I build with the patients and the families. That's what keeps me going! (smile)
DeleteI think this is a very good example of the technician model. The textbook did not do a very good job at explaining this model (I feel like anyway) so to hear a "real life" example was beneficial. I can see how patient interaction would differ significantly in the OR versus out on the floor.
ReplyDeleteGreat example of the technician/consumer model. Even though the physician may not be the best at interacting with the patients when they are conscious, they still provide excellent care for them during surgery.
ReplyDeleteI will focus on the partnership part of the five models of the doctor patient relationship. I feel it is important for the physician to include the patient as a partner. If the patient feels more as a part in the healing or managing of their disease, they will be more likely to follow instructions and medications. The patient must feel like they have a part in their health and healthcare. I feel more physicians should take a good look at how Dr. Gawande approaches his patients. At the beginning, he just wanted to "fix" his patients. Now, I feel he wants to partner with the patient. He has learned how to have difficult conversations with his patients. He has learned how to tell them when treatments are futile. Dr. Gawande respects his patients and lets them know when it is time to get the most out of the life they have left.
ReplyDeleteHow do we see physicians using the five models of the doctor patient relationship. The first being the paternalist model. We see this every day in the ER. Physicians tell them what they should do, and that this would be the option they would choose for their family member. The book makes a good point that "In a pluralistic society such as ours, the assumption that the physician and patient has common values about health that may be mistaken."(DeGrazia, Mappes, Brand-Ballard, pg. 75, 2011) We see the many repeat admissions because many people do not want to change their behaviors. The physicians must learn that the society today most people do not want to be told how to live their lives.
ReplyDeletePartnership, being the second model, consists of a good doctor-patient relationship. I like that this addresses the shared values between the two parties. we see ore and more that the doctors trying to work with the patients and their ideas of what their health should be. If the patient is happy being morbid obese then they can try to maintain the patients ability to function by alternating different therapies. This could save healthcare a ton of money. Unfortunately, we all know doctors that do not care about their patients or those who do not have the skill to communicate with their patients. This can make this model hard for some to follow.
Rational contractors, according to Veatch, is the only realistic way to share responsibility, to preserve both equality and autonomy under less than ideal circumstances, and to protect the integrity of various parties in healthcare.(DeGrazia, Mappes, Brand-Ballard, pg. 76, 2011) I think this gives to much to an uniformed patient. I do not see this in my place of work.
Fourth model is friendship. That the two parties have a mutual trust and confidence. Unfortunately, it takes time to develop a relationship that falls into this model. I do see this with certain patients that come in often and actually ask for a certain physician. More than not, I do not see a genuine trust in a physician that you have only seen once.
The physician as the technician if the final model. We see this model used more with the surgeons and Internationale radiologist. The relationship is dictated by the technical aspect with little or no attention to the other four models. The physician states what has to be done, gets consent, and then performs the task. Usually when the procedure is over, they have little contact with the patient. They are trained to perform a certain service and when they are finished the patient moves on.
I like that Dr. Gwande follows the partnership model to his practice. I feel he gives respect and trust to his patients. He is an active listener to his patients and gives proper feedback without the patient feeling he was wrong or attacked. Interesting that he was raised in Athens, Ohio.
DeGrazia, D., Mappes, T. A., & Brand-Ballard, J. (2011). Biomedical ethics. New York: McGraw-Hill Higher Education. pg. 74-82