Autonomy begins with doctor-patient dialogue

Advice is tailored to patient’s personal needs

For patients to have both the autonomy and medical advice they need, physicians must establish an active dialogue, says Timothy E. Quill, MD, an internist and professor of medicine and psychiatry at the University of Rochester (NY). While this takes more time and effort than just recommending treatments and dispensing prescriptions, it leads to better medicine, he says. Quill offers the following advice to physicians who want to adopt a model of "enhanced patient autonomy."1

1. Discuss both your medical knowledge and the patient’s perspective.

"You use your knowledge of the [clinical outcomes] statistics and your personal experience with the disease process and share as much of that as the patient cares to hear," says Quill. "[Meanwhile,] you’re listening for the patient’s experience."

For example, if a patient has a choice between radiation therapy and chemotherapy for breast cancer, they may be influenced by the experience a loved one had with one of those treatments. The physician needs to understand the context of a patient’s treatment decisions, he says.

2. Acknowledge the importance of personal experience.

In addition to the patient’s prior experiences with the illness or treatment, the physician also has a personal perspective based on years of practice. The physician should share that with the patient, Quill says.

"There are good statistics [from clinical studies] about many things in medicine, but there are still lots of things that don’t have good statistics," he says. "[You may say,] ‘This is what I’ve gleaned from 20 years of practice. My experience tells me such and such.’"

3. Begin by discussing general treatment goals.

Before getting into the details of specific treatment choices, the physician should determine the patient’s overall goal, Quill says.

For example, if a patient has a form of cancer that doesn’t respond to traditional treatment, the patient needs to decide an approach. "You have to think about whether the goal is to search out any long-shot therapy that might work, like experimental therapy, or whether the goal is to keep the patient comfortable, a palliative care approach," he says. "That general approach has to be discussed first before you talk about the nuances of pain therapy."

4. Accept the patient’s right to make the final choice.

The patient, after all, is the one who will live with either good or bad effects of treatment, says Quill. Their choices should arise from a full understanding of medical information and the physician’s recommendation. Through an open exchange, the doctor also should learn about patients’ personal values and experiences that shape their decisions.

If the physician disagrees with the patient’s choice, he or she needs to enter into an "intense exchange" with the patient to try to reach common ground, Quill says. "Usually I think doctors and patients achieve agreement [about treatment decisions] if they’re willing to come to a good understanding of what the issues are," he says.

Reference

1. Quill TE, Brody H. Physician recommendations and patient autonomy: Finding a balance between physician power and patient choice. Ann Intern Med 1996; 125:763-769.