Decision making in medicine is a complex process based on multiple factors such as the chance of causing harm, the cost of the treatment, evidence to support the treatment and many, many other issues. Most often when doctors discuss why they have chosen a treatment they talk about “standard of care.” Ideally standard of care is based on reproducible studies, which have also stood the test of time. Quite often studies are flawed or evidence has changed or the circumstances of a study are different than your circumstances, and in this situation a doctor must use other tools to determine the best treatment.* In the case of classical osteopathy there are very few studies simply because the method of treatment is too complex and individualized to actually study effectively using the scientific method. Two critical factors are often not discussed in an analysis of why a medical treatment or test is chosen or recommended. The first is physician experience (both personal and with patients) and the second is culture of training. Because medicine is more art than science, these are viable tools in decision-making – if they are used consciously.
To explain the first issue I often use the example of a New Yorker cartoon that was given to me years ago by my grandfather. In it, a rabbit wearing a white doctor’s coat and stethoscope, is speaking to a man in only a hospital gown and his underwear, sitting on an examining table. The rabbit says, “I think you need more carrots.” this comical cartoon is in fact the way some practitioners make decisions about health care. In some cases, the decision is based on a personal or family experience with a treatment. In other cases it is based on a mentor or organizations recommendations. Sometimes this is in fact the best way to make a decision but what is most important, when using this method is that the physician is conscious that his or her personal experience is directing action.
The second factor is “culture of training.” This method of decision-making is often the result of an effort to deal with shear volume of information available. It is impossible for any human to research and know all treatment options and to know all the evidence or data that supports each option. As a result doctors often follow the lead of a respected mentor or physician with whom they have practiced. Although these may not seem like the best ways to make important decisions, at times they are the only option available to your doctor. It is up to you to be informed about your health care and how your doctor makes decisions. In the end, it is important to understand that in most situations there is not a single standard treatment that will work for all people. Exceptions to this generally include conditions that are emergencies, like trauma and heart attack and fractures, which usually have clear treatment protocols. The ratio of risk to benefit is ultimately the basis of most decisions in medicine. Osteopathic manipulation using the Biodynamic model is unique in that it has an extremely low risk potential. Second to Biodynamic treatments in low risk are changes in nutrition. For this reason, and because they are profoundly effective in many situations, these two treatment modalities are my first choice for most patients.
Another important issue to understand is that doctors and patients often have different agendas. Doctors generally have a series of conditions and lab values, which they are trying to correct – primarily these have to do with potential development and consequences of diabetes and cardiovascular disease. Doctors look at risk factors such as your weight, your cholesterol, your blood sugar and your family history and determine what medical treatment you should receive. Meanwhile patients usually don’t go to doctors because they noticed their cholesterol was high but rather they are concerned about how they feel, how much energy they have, and of course if they are experiencing pain or many other symptoms. It is important to be clear about what a treatment plan is going to address – lab values, potential disease or symptoms. It is equally important to know what health goals a patient has. Do they simply want to be relieved of their knee pain, or are they interested in improved vitality? Is it enough to be able to get through work or are mood changes powerful enough to warrant attention. This focus on goals is most importantly in the hands of the patient, but if the physician is not aware of them it is impossible to align agendas.
Relationships Need to be Rebuilt
The current climate of medical care is strained to the point of breaking. Doctors are frustrated with insurance limitations and time limitations. Patients feel that they are not heard or seen and that they are waiting too long for too little. Communication between doctors and patients is so limited that no one is satisfied. Change is not easy but these issues have informed how I practice medicine. Communication and partnership are key and open honest discussion of treatment options and agendas for healing are the basis of how I make decisions.