The three types of clinicians

I've recently read Being Mortal by Atul Gawande. If you haven't read it, I highly recommend it. It's an important read for anyone who works with the elderly, has aging relatives, or is at the age where liver and onions start to look appetizing at 4pm at the local diner. Atul is a doctor whose father is nearing the final stages of his life, and throughout the novel he dives into what matters most to us and those around us as we reach our end of days. Most importantly, he provides insight into how to enjoy those days and maintain your quality of life.

The chapter I keep coming back to is called "Hard Conversations". Dr. Gawande references a short paper by Ezekiel and Linda Emmanuel, two medical ethicists who describe the three main types of relationships that clinicians create with their patients. They specifically reference doctors in the paper, but these relationships are applicable for all healthcare workers.

The first--the oldest, and most traditional kind, is a paternalistic relationship. We as the experts, make the critical decisions for you, the patient, based on what we know to be in your best interest. This happens more often in vulnerable populations such as the elderly. While a bit old-fashioned, this type of relationship continues to be commonplace in many healthcare settings. Patient autonomy matters little in the paternalistic relationship. Think of it as the "doc knows best" style.

The second relationship is the antithesis of the first. It is referred to as the informative relationship. We tell you the facts and figures, and the rest is up to you. We give you choices from A to Z and the onus is on you to make the right choice. The patient becomes the consumer and the doctor's job is to provide the skills and expertise to carry out the patient's desires. This can work swimmingly, when the decisions to make are straightforward and the consequences are simple. Patient autonomy is at its height in the informative relationship. Think of this as the "patient is always right" mentality.

In truth, neither option is ideal. As patients we want options, but we also want guidance. Here lies the third type of relationship, the interpretive one. An interpretive clinician asks important questions such as, "What is most important to you?", and "What are your fears?". The clinician's job is to help patients to understand what they want before outlining their options. This form of shared decision making provides guidance while respecting patient autonomy. It's the balance between paternalistic and informative.

To become an interpretive clinician takes time, and patience. Wants can be fickle, and it can be difficult to dig deeply enough to understand what makes our patients tick. But if we transform our practice to act as counselors rather than decision makers or educators, we will give them the tools and understanding to make tough choices by having

hard conversations rather than avoiding them.

I'll say it again--Being Mortal by Atul Gawande is a must-read. It's not an easy one, but, it's an important one.

#patienteducation #patientempowerment