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Tuesday, November 9, 2010

The modern physician: Consultant, Motivator or both?

As physicians, are we just consultants? Or are we more? Beyond just presenting facts, should we play a part in motivating patients to heed our advice? Many would say yes to the latter; physicians must not only educate but they must motivate as well.

In the book we're reading in school, The Medical Interview: The Three Function Approach, we find the following:
Some might argue that a physician should not be in the business of motivating patients to change. Perhaps physicians should just inform patients of their condition and make recommendations. Perhaps patients should have the right to decide independently whether they want to follow treatment recommendations, without the added burden of physicians' attempts to motivation.
This is essentially my current sentiment about what the legitimate role of the physician should be. But I'm amenable to changing my stance if I can get a better reason than the one offered by the author of the quote above. His dismissal of the 'doctor-as-consultant' position is merely that:
While there is certainly some merit to this position, most physicians accept that health enhancement strategies are part of the modern practice of medicine.
All right, so most doctors accept that 'health enhancement strategies' are part of the modern practice of medicine. But why?

I have several reasons for thinking that the 'doctor-as-consultant' rather than the 'doctor-as-motivator' is the legitimate one and it has mostly to do with my view of individual responsibility and freedom.

Patients freely engage in a relationship with a doctor for the purpose of improving their health. They are paying the doctor for his time, his training, his expertise and his recommendations. The doctor's duty is to give the patient these things and to make sure that the patient understands the options at hand as best he can. Beyond that, in my opinion, it is the responsibility of the patient to weigh those options, and to decide whether to accept the recommendations and treatments of the doctor.

So long as the patient is informed of the consequences of taking one action over another, I don't think the physician has an obligation to motivate the patient toward any decision.

My hesitation with the 'doctor-as-motivator' role is that it is paternalistic, even if at the core the intentions of the doctor are beneficent and altruistic. By going the extra step and saying, "Now, Mr. Smith, do you think you can eat a little less salt? If you don't do that, you could end up with much bigger problems down the road. That wouldn't be good for you and your family," I think you step over the line of patient autonomy. I realize that there is so little objection to physicians trying to motivate their patients to change because there is no ill will or malice in that action. It is, after all, the patients interests we have in mind. But that's precisely the problem for me. When I try to motivate a patient to change, it's MY desire that I'm imposing on the patient, not his own. I am supplanting his decision making process for my own.

I know I might be over thinking this. I admit that being inspired or motivated to change could very well be part of the total service physicians offer. That might be what the patients are paying us for, in which case, I don't have a problem being a motivator because it's the patients desire to be motivated. But I just have a hard time swallowing the fact that people should need to be prodded or nudged to care about their health. I'm also pretty cynical when it comes to the idea of changing minds. I don't really think you can change a person's mind. They have to change their own minds, and that requires information and will power. I can offer the information but not the will power.

One of my classmates said to me, "Alex, you just don't like being told what to do, and that's why you have a problem with this motivation stuff." And I said, "Yes, you're right. But I have an even bigger problem telling other people what to do. I don't feel like it's my place. People are free to make good and bad decisions without my coaxing. That's what it means to be free."

What started this whole dilemma was a simulated patient we had in our practice course. She was the 'difficult' or 'resistant' patient. Essentially, this woman had high blood pressure and was making poor lifestyle choices. She was sent to the doctor by her husband because he worried she might be at risk for heart problems. True to life, this patient kept insisting that nothing was wrong with her, that she was in great shape, that she felt fine, and that she had absolutely no desire to change anything. Admittedly, this was patient was really an actor, but our instructors confirmed for us that this type of patient scenario was very common in the clinic.

Which got me thinking about all of this. If a patient is utterly uninterested in improving her health and is unfazed by the potential consequences of her actions (presented by the doctor), what more can we do? What more should we do? As an adult, its your responsibility to decide what's important to you in your life. If eating certain foods or living a certain way is more important to you than the prospect of better health and a longer life, who am I to try to change your mind. Some might say, 'well, that's what doctors' goal is - to improve patients' health'. Yes, it is, but it's our goal only if it is their goal. It can't be our goal and not theirs. And I would add to that, we shouldn't have to make it their goal. Our proper role is to give them all the information and expert opinion for them to deliberate and decide if their goal is going to be improved health, but we can't force it on them, nor should we.

As I said, I'm not completely convinced that my position is the correct one, and I'd love to start a conversation on this. I welcome any and all comments.


  1. When you go to listen to a speaker, see an advertisement for a product, even something as simple as reading the label on a type of food, there is a message, pulling you in: someone or something is saying "pick me." Each of these things is, in its own way, trying to convince you that you should listen to it. Yes, ultimately you have the choice to pick what candidate you vote for, what products you buy, what food you eat.. but in each area, a serious argument is made by each side. They sure as hell try to go out of their way to get their point across. Without this motivation to sway someone one way or the other, I hardly believe the majority of the population would blink an eye.

    In medicine, as well as in many other areas, coaxing and encouragement towards 'something better' may not always be immediately realized; the obstinate, hypertensive woman may think she is fine, until she is made aware that her habits may lead her to dying before her grandchildren are born. I think there is a certain truth in "seeing is believing".. if the patients can see where their habits will lead them; if the smoker can see a tarred up and cancerous lung; if the obese woman can see the extra pounds of fat in a jar, if the promiscuous man can see the number of woman that he will give STDS to. physically seeing the repercussions to their current decisions might generate a greater percentage of patient adherence.

    Basically, a physician has gone through extensive training to know what constitutes staying healthy, staying sick. People konw this, and that is why doctors' offices are constantly full. The disconnect comes when they can't see what the physician is telling them to be true. I think personalizing the diagnosis and treatment should be encouraged and may end up leading to more compliant patients.

  2. Hey Alex,
    Like you, I find myself torn about the docto's proper role and the risks of overstepping our boundaries. However, to be the devil's advocate, I've also thought of a few points that, to me, call for the doctor play a bigger role in motivating patients.
    Primarily, I think the doctor can be a key source of information. There are still people who think diabetes comes from eating too much sugar as a child or have trouble understanding the difference being able to pass on a disease genetically versus actively being able to "catch" a disease from a family member. In our particular case, the patient didn't understand the link between salt and high blood pressure or the different between being on their feet all day at work and actively raising their heart beat by doing aerobic activity for 30 minutes a day. So maybe it's not a question of motivation, but rather presenting a more cohesive set of facts. To tell a patient more exercise is an option for them is one thing. To show them how easily they can fit exercise in to their schedule is another.
    Another important argument in favor of motivation is that bad habits are learned somewhere. If a patient surrounds him or herself with friends who smoke, or if someone is raised in a family and community that relies on a BBQ and fried diet, there may not be another support system available to the patient. Sadly, I think this is a fairly common scenario; healthy people tend to surround themselves with other healthy people and vice versa.
    Certainly doctors aren't obligated to motivate their patients (legally or otherwise). But I think we also need to recognize that merely presenting a patient with facts may not be enough, depending on their circumstances and education level about their own body and health maintenance. I also will add, as a side note, that I think the appropriateness depends on the relationship the doctor has with the patient. Primary care doctors will be more effective motivators than the cardiologist meeting the patient for the first time. And by all means, if the patient is not interested in "being motivated," the doctor should not push.

  3. Cill and Kahli,
    Thanks for starting the discussion. Good points made by both of you. You know, I'd love to conduct a survey amongst a large group of diverse patients and ask them if they go to the Doc to be motivated as much as informed about their problems. I thought more about other roles that one might consider as 'consultant' like, such as a personal trainer, and undoubtedly people go to a trainer not just to learn how to get in shape but to be pushed to get in shape. If that is what people want from a doctor, I can supply that. I guess I just have a hard time wrapping my head around the fact that people need to be persuade to care about themselves. I know it's true, but I like to pretend its not.

  4. This is one of those issues where I part company with orthodox libertarianism. I agree with you that doctors shouldn't care only about their patients' health if the patients value other things more - the goal is to optimize happiness not lab numbers. But to me that goal can't be achieved by hewing to the single algorithm of "tell them the facts and then shut up."

    That "consultant" method works very well when dealing with savvy patients with a working knowledge of both health and their own utility functions. But we're also living in a world in which many patients strongly believe false things about health (thanks Google!) and can also have shockingly low future time orientation. What struck me about our standardized patient was not that she didn't view high blood pressure as a problem, but that she didn't seem to place a high value on her future health, as long as she is healthy today. Skepticism I could understand; this was closer to irrationality.

    At the best of times, there is a tension between the consultant ideal of maximizing patients' life happiness and the paternalistic ideal of maximizing patients' health. But in this case the consultant model doesn't even maximize happiness well - ill-informed or uncontemplative patients can make bad decisions that harm both health *and* happiness, and a strong paternalism is better at helping them achieve both than an agnostic consultant mentality. Given this situation, you can choose to be uncompromising on trying to obtain your goal or uncompromising in the methods you use - but not both. To me, it the goal is more important than the process.

    In this model, patient autonomy is not meaningless. Patients still choose to go to doctors, and know that these doctors are partly in the business of making normative prescriptions. Rational patients who value individual autonomy are still free to take the information and ignore the advice. But for those who would otherwise be driven to error, a cautious, humble application of paternalism can lead to unambiguously better outcomes. And that seems to me to be the best way to achieve doctors' goals.

    The flip side of this is that if you're going to be strategically paternalistic, you'd better be sure that your moral suasion is well-founded. There has a been a fair history of doctors making overly confident prescriptions based on poor science, most obviously in the area of nutrition. Doctors who take up the white-coated man's burden need to be extra aware of the limitations and biases of the science on which they base their practices. (Read the recent Atlantic article if you haven't already: http://bit.ly/93zTjC) As the great sage Peter Parker said, with great power comes great responsibility.