Medical paternalism and reverence - UMAT Exam

Over the last fifty years, attitudes that patients have towards their treatment and the reverence they have for their physician has been under a steady evolution. It was only a relatively short time ago that patients would leave a majority of decision-making regarding the management of their medical conditions completely to their treating doctors. For their part, doctors were generally very comfortable with this relationship, and justified their paternalistic practice on the wealth of their medical knowledge, which created a significant division of power between physician and patient. It will be the purpose of this blog to investigate how these attitudes have changed, in contemporary medical practice, and to determine whether doctors are still revered in the community as they were in decades past.
 
Decision making in the earlier parts of last century were very much unilateral; physicians would more or less tell the patient what treatment they should receive for their particular diagnosis. In society, doctors were highly respected, and their word almost taken as gospel. In the modern setting, there has been a big shift towards a ‘shared decision making’ model. This is in response to the identified need for patients to be invested in and engage with their treatment, mostly because patients have demanded a greater role; in consequence the vast power differential between physician and patient has been decreased markedly. This shift in patient to physician dynamic is also due to the increased access to knowledge by patients through the internet media and the subsequent (perceived) understanding of medical conditions by these patients.
 
Shared decision making is an active dialogue between physician and patient with the goal of arriving at mutual understanding and agreement on a treatment plan. There has plainly been a shifting balance between physician expertise (paternalism) and respect for patient autonomy. Studies of shared decision-making link increased patient involvement to improved treatment adherence, disease coping, and quality of life, whereas lack of patient involvement correlates with lower adherence to treatment, patient satisfaction, and health outcomes. The advantages of shared decision making are clear: maximizing the likelihood that both patient and physician will be respected, satisfied, and invested in the outcome.
 
However, the model of shared decision making has also had its own problems. Where patients have poor health literacy (whether they realise it or not), or they aren’t fully competent to engage in complicated medical decision making, this doctrine can collapse on itself. There are critical implications to the loss of physician-driven decision making in medicine. In many fields (e.g., law, education, economics), it is generally accepted that decisions are best made by experts. Within their respective fields, experts are charged with understanding the nuances required for best practice of the profession. Physicians are obligated to ensure quality and value in health care through education, expertise, and ethical practice patterns. Despite the commonly held opinion in much of society, medicine is not a simple consumer-producer market, and physicians cannot be forced into a fully patient-autonomous system. Information flow between physician and patient with direct implications for decision making should be guided through the application of values that promote ethical decision making.
 
Anecdotal evidence suggests that doctors are still broadly respected in society. However, physicians are not as revered as they were in decades past, where the practice of ‘doctor knows best’ was in full-flight. Due to changing socio-cultural practices, the increasing knowledge of patients, and the emphasis the medical profession has put on shared decision making, doctors have lost their divine status as health monarchs. It is difficult to decide whether this is unilaterally grossly beneficial or detrimental: somewhere in-between in probably a more accurate assessment. It is overwhelming positive that patients now interact more in their treatment and are engaged in their healthcare, as it ensures prescriptions are more closely followed and promotes a more collaborative model between doctor and patient. The downside is that physician advice is more often ignored due to misunderstanding of self-collected medical information by the medically illiterate patient.