Monday, April 9, 2012

The One Question I Won't Answer


As I looked at my screen to check which patient was next, seeing her name made me smile.

The patient was a delight. I had delivered her first baby two years ago, an adorable baby girl with curly blond hair and rolls on her thighs. The patient pushed like a champ, but despite her efforts, her 10 pound bundle of joy entered this world through a low transverse abdominal incision.

She was newly pregnant with baby number #2.

A perfect flutter of a heart beat was seen on the ultrasound, and all was good.

“Doc, do you think I should try for a VBAC (vaginal birth after c-section) or have a planned c-section this time?” she inquired, as we finished up with the usual questions.

I carefully reviewed the risks and benefits of each, encouraging her to weigh which option would be best for her.

As I finished, I noticed she was pursing her lips in anticipation of a question that she could barely contain.

“But Doc,” she asked smugly, like a jeopardy contestant who knew they had the right answer, "What would you do if it were YOU?"

The favorite question. I smiled and leaned back on my rolly stool.

“Nope.” I said as I shook my head back and forth with a smile, "I don’t answer that one.”

Somewhere there has to be a Readers Digest Article, ‘Top Ten Questions to Ask Your Doctor’ and this is probably #1, based on the number of times that I have heard it.

Initially, when I started practicing and my newly board certified brain was bursting with memorized textbook knowledge and randomized controlled trials, I would fall for this trick. I would rattle off my personal opinion on such matters. Because obviously, I knew best.

No, I personally wouldn’t VBAC, but sure, you go right ahead.

It didn’t take me long in practice to realize that every women is unique. I was biasing these women with my personal opinion on issues that really, I had no business discussing.

I am not saying I don’t give advice. Of course I do, I am a doctor. I give my best medical recommendation in all situations.  However, I do not give patients my honest, personal opinion of what I would do in their specific situation, because I am not them.  And I am not in their situation.

In obstetrics there are multiple situations when women really need to decide for themselves:

VBAC vs. C-section

Natural vs. epidural

Circumcision vs. no circumcision

These are just a few of the very personal decisions that women need to make for themselves. Options that should NOT be decided by their moms, NOT by their friends and definitely NOT by me.

Is this a question you answer?

20 comments:

  1. I'm not sure I agree. There have been several recent studies that have shown that some/many patients want their doctor's guidance in making these kinds of decisions -- guidance beyond, "Here are the pros and cons of each choice, now you decide." You obviously have an opinion, and if I were your patient, I'd want you to share it with me, whether I ended up following your advice or not. That's why I'm paying you, after all.

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  2. It's funny I should read this post now. I am in PA school and nearing the end of my first year, so in 7 short weeks I will be on my rotations, and this topic came up in my ethics course. Our instructor cautioned us against answering this question for the reasons you mentioned but also due to the possibility that if we were to share our opinion and 'recommend' one option over the other and something went wrong for the patient there is potential to see ourselves with some serious trouble on our hands....I don't know if that sort of thing happens in reality but it is reassuring to see that even doctors won't answer that question!

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  3. I completely agree. It's impossible to give an unbiased opinion as physicians, even if we try to. And, as anon above pointed out, yes, you can get in trouble if a patient decides to go your way and then something "bad" happens. I'd rather let them choose based on their life and what suits their needs best; after all, I'm not them, I don't live their life nor struggle with their particular concerns. Every person is different.

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  4. Alas, you can only control #3. Their moms and their friends feel free to give them (often bad) advice....

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  5. I sometimes do share what I would do - depends on the situation and the patient - but I always share the process by which I come to the decision, because that's generalizable in the way my personal preferences and values are not.

    Our patients do want and deserve more than a menu of options. They deserve our expertise - which is not the same as our personal choice. I ask them about their values, their fears, and their priorities, and then make a recommendation

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  6. Just to clarify I do always give a medical recommendation, but as Jay pointed out this is not always the same as my personal choice.

    THis post came out of my realization that my VBAC rate went up after I stopped answering this question. A VBAC is a great option for many patients, I personally would not choose it though. Even when I explained to the patients why I wouldn't VBAC (no desires for vaginal delivery) I still feel this biased them with my personal opinion.

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  7. Great question. In some areas of medicine I think the MD's opinion should stay out of the patient's decision making process and perhaps the very personal experience of childbirth is one of them. But there are situations in which I wish patients would ask that question - code status comes to mind. Do I want to spend what could be the last minutes of my life having my chest cracked? If I am young with no medical problems? Ok. If I am elderly or saddled with many medical problems? Absolutely not. They can still decide for themselves, but we are the ones who have had benefit of seeing codes gone wrong (and in your case RH+, uterine rupture I imagine). It is those experiences that inform our personal decision making.

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  8. But to be clear, I very much support the decision to NOT sure your personal opinion if it in no way would change your medical recommendation, especially in an area like childbirth where women go into it with so many many expectations about what should and should not happen.

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  9. I usually answer questions like that with "I honestly don't know what I would do". Until you are actually faced wtih a decision, you may not know what that answer would be. I get it with mastectomy vs. lumpectomy/radiation. I "think" I know what I would do, but honestly? I don't really know.

    Kellie (General Surgeon)

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  10. I love what Jay said - patients deserve expert opinion. Not to be confused with personal opinion. We are in our professional role at work, not two girlfriends talking over lunch.

    When I had my brain tumor removed I was lucky to have had the best surgical team in the country who told me they will use this particular approach because they think it is my best option. They did not ask me how I want my skull cut.

    Medicine today became consumer service. I personally heard consierge physician in my old practice ask patient if patient wants abdominal ultrasound done or wait and follow up with labs or have surgeon do exploratory surgery.

    I argue that patients ask this question when they are confused and do not know what is best, because they are made to be their own doctor.

    I wonder if it is fair for you to answer: choice A carries more risk for you and your baby. Choice B is safer. I want the best outcome for you and the baby. Then wait and see what they say.

    A few times I answered question what I would do if it were my family (though adding this is very personal matter). To my surprise patients felt relieved because that is what they would have done too. And there was immediate trust.

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  11. As an early trainee, I am definitely still learning how to deal with this question. Sometimes there is a fine line between personal opinion and expert opinion, especially with end of life issues where I think we develop our own personal opinions as a result of seeing unnecessary prolongation of life and underuse of things like hospice care. So I have come to try and just be as detailed and honest about these issues as I can be in a professional way without just giving a personal opinion. I also think that people are at baseline very underinformed regarding end of life care and I find these "what would you do" discussions the most difficult. Otherwise, People constantly ask me if I would have whatever surgery they are having, and aside from appendicitis, I pretty much never give a personal opinion, because in all honesty, I really don't know - every person's situation is SO different and personal.

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  12. Some patients want and need more direction than others - and the context matters. I recently saw the dentist for an abscessed tooth. I'd been in pain for three days and hadn't slept at all the night before. He offered me root canal or extraction, and wanted to have a long, involved discussion about the pros and cons of each. I wanted the pain to stop, right.that.minute. It seemed clear that if he took the tooth out, the pain would stop, so that's what I picked - and then he hemmed and hawed and said "are you sure?" about five times, until I wanted to pick up the dental pick and stab myself with it.

    Sorry. What was I saying? Oh, right.

    Anyway, very few of us have any training in the kind of conversations that bridge the gap between "doctors making all the decisions" and "patients being their own doctor". Facilitating decision-making is a skill, just as delivering babies or placing a central line, but we don't teach the skill or model it.

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  13. Tough question! Lately I have been seeing patients obsess over all the wrong things--I think it's hard for someone with no medical training to understand magnitude of risk of one treatment vs another. I think if my personal and medical opinions were undoubtedly in sync, I'd answer the question, since I think most patients just want you to sum up your recommendations with an easy one-liner. (I am imagining me with my financial counselor or plumber--just tell me what you would do, since all of this information is foreign and overwhelming!)

    If it really doesn't matter either way, then no, I wouldn't answer.

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  14. Anon@2:55 -- Thanks for bringing that to my attention. You're right, it is incredibly offensive. I'm sure someone on this forum will say that they're trying to promote tolerance and diversity by including a range of doctors with a variety of viewpoints, but comparing abortion to the holocaust really crosses the line in my opinion.

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  15. >>code status comes to mind. Do I want to spend what could be the last minutes of my life having my chest cracked? If I am young with no medical problems? Ok.>>

    No, NOT okay. I'm young with no medical issues, but I'd rather be dead than survive such a barbaric ordeal. Definitely. It's not something I want, under any circumstances.

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  16. Anon above - what original writer meant is when you are young with no medical problems you have a chance of surviving the code. Thus it is understandable that young healthy people want to be full code. Your thinking was polarized.

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  17. Excellent post, as always, RH+! It is often an ethical sticky wicket, and I find myself dodging this question several times a day. I actually came across this question yesterday when discussing whether to proceed with an induction that was not progressing vs. moving toward cesarean delivery. I laid all of the options out on the table for the pt and we discussed the pros and cons of each. When *that* question arose, (What do you think I should do?) Instead of offering my personal opinion, I discussed the reasons why one decision may favor another based on the medical presentation of her situation from both sides of the fence, but left the decision in her hands. When we delivered her 10 + lb baby by cesarean a short while later, we certain we had made the correct decision together! :)

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  18. Interesting post. I will sometimes offer my personal experience to patients. For instance, when I am discussing the quad screen I will say that I did it when I was pregnant because we live in a town without a NICU and only a level 2 nursery, so if there is something like Down's or Spina Bifida we want to know about it so we can be prepared and potentially deliver elsewhere if necessary. On another note, during my own c-section delivering my 9 pound 8 ounce daughter, the OB doc said "you're not going to have a VBAC are you?" I don't think he would have said this if I wasn't a doctor, but I can very confidently say that I am looking forward to having a scheduled c-section next time around whenever that may be!

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  19. >>Anon above - what original writer meant is when you are young with no medical problems you have a chance of surviving the code. Thus it is understandable that young healthy people want to be full code. Your thinking was polarized.>>

    The chances of surviving a code are greater when one is young and healthy, but they still aren't great. It's not worth it.

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