This is the second in a two-part interview with Dr. Peter Ubel, a physician, behavioral scientist, and author of the book Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together. Missed Part I? It’s right here!
KARAN: You referred to patient education earlier, not just in terms of treatment information but also the types of questions to be asking. But what about the former? Our generation is definitely comfortable using technology to look up health information, and we get a ton of information through news, magazines, and the general media. But not all of it’s good. So how do you recommend people sift through the good and bad information out there, when they’re trying to inform themselves before a visit to the doctor.
DR. UBEL: Of course, the education system should help people learn how to objectively look at things and help them when things go over their heads.
But the other thing I’d say is, print out and bring in the stuff that you see online, show it to your doctor, and let them tell you what’s right or wrong about it. Then they’ll know what you care about more than they did before, which is really valuable. Your doctor shouldn’t be threatened when you bring these materials in; they should be happy that you’re helping focus the visit on the topics you care about. If you’ve got misconceptions that are affecting the way you’re behaving, like what pills you’re taking or not taking, the doctor should be happy to have a chance to address those misconceptions.
So: print it out; bring it in.
Speaking broadly, younger patients are probably more likely to have sporadic relationships with the healthcare system—moving around a lot, without a constant PCP, potentially also going to MinuteClinics more often. As decision-makers, do you think that affects the things we should be thinking about?
There’s advantages to having someone you’ve seen multiple times if you have a chronic issue, but if you’re talking about a series of unrelated, acute complaints, then you have to develop the skill of assessing a new clinician every time. You have to figure out quickly who’s good and who’s not, just like you did with that orthopedic physician—I guess people in your generation will have to get really savvy about that.
In terms of assessing a clinician, there are very obvious things to look out for—does he or she listen to me? etc.—but are there more subtle things to think about when you’re assessing a doctor?
I think when you pay money to go to a doctor, you deserve to understand the things that are going on in your health and what can be done about it. Any doctor that makes you feel rushed to answer your question, to help you understand the situation, that’s when a warning light should go off. Any time you feel like the doctor’s trying to control the agenda too much, that’s another red flag.
I was also thinking about how, as we were growing up, our parents took us to the doctor and made our decisions for us. But as we get older, that situation might switch. We will be taking part in our parents’ medical decisions more so than the other way around. I was thinking about how that might lead to some new problems, like if one parent gets sick and the other parent’s views differ from our own, maybe because of generational differences. We were talking a lot about what the patient wants versus what the doctor might be talking about—what if the patient’s family can’t even figure out what they want?
Oh, yeah. Welcome to the third year of medical school. You’ll be spending a lot of time on these kinds of disputes, and they’re messy. There are times when the patient is still alert and able to participate, but still it’s the family’s disorder that dominates everything because they don’t want to go against what their loved ones want but their loved ones aren’t on the same page. So you’re as much a mediator as a physician, which is (I think) an enjoyable part of medical practice , but also very challenging.
What about from the perspective of the patient? How do we come to a conclusion?
In the abstract, it’s really hard to know what to say. People always say you should make decisions based on what the patient’s best interests are. A lot of times that’s not really clear. If everyone could agree on what their best interests were, and what they want (which are hopefully the same thing) then we wouldn’t even be in this mess. So if it’s a matter of the patient’s interests versus the family’s interests, you ought to try to err on the side of the patient’s interests. I just think that’s how most of these pan out. Decision making is messy!
I guess that’s the only way to sum it up.
I’ll tell you what the advice I give to families is: durable power of attorney for healthcare. It means: tell me who I need to talk to for difficult decisions if I can’t talk to you. As a doctor, if that means I need to speak with you, the son, instead of the wife, then I need to know that. Now I’m still, as a clinician, going to try to get everybody on board and everybody happy. But if push comes to shove, I can say, “Ma’am, your husband asked that your son be the one making these decisions, maybe because he felt like it’d be difficult for you to distance yourselves from these types of decisions. So let’s try to work together, but it sounds like what your son wants is really where we should go.” So durable power of attorney is huge.
Is it pretty common for older adults to give their children durable power of attorney?
If they don’t assign anyone, the typical understanding is that it goes first to the spouse, and then to the kids. So if you’re happy with your spouse making the decisions, then you can be passive and the system will work. Maybe that’s why a lot of people don’t go to the effort of explicitly naming a proxy—I don’t know if it’s because they’re happy with that or because they never actually think about it. You’ll see a lot of this in medical school, when people name someone when there’s special conflict and when they really trust someone more than others for whatever reason. And it’s way more useful than a “living will” or anything like that, which will almost never be specific enough to fit the circumstances at hand.
So the difference is, a living will is more like an algorithm: if this happens, then I want this decision; if that happens, I want that decision.
Exactly. And those specifics are very hard for people to imagine. Even if they do mention the circumstances that they’re in, you still can’t actually predict if that’s what they currently want in the situation. If you’d have asked for a living will from my grandmother, she would’ve said “Kill me before you put me in a nursing home.” Yet when we put her in a nursing home, she had three of the best years of her life.
Karan is a first-year student at Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.