A couple of generations ago medical culture was aloof and authoritarian. Doctors did not give advice to patients, they gave orders. Patients were expected to follow those orders. Questions might have been tolerated, but patient requests for explanations or suggestions for a different approach were considered very unusual.

I thought this paternalistic model of doctoring ended long before I was trained. I was trained to think of the patient’s autonomy as the core of the patient-doctor relationship. I was taught that I should explain various alternatives, answer questions, and allow the patient to make the final decision directing her care. Doctors were expected to make recommendations, but also to encourage questions, second opinions, and exploration of alternatives.

I guess old habits die hard. A recent study in Health Affairs interviewed 48 patients in the San Francisco area about their interactions with their doctors. Most of the patients were over 50 years old, lived in affluent neighborhoods, and were highly educated. Nevertheless, the patients revealed several obstacles to having discussions with their doctors about their treatment plan. Patients reported that their doctors can be authoritarian, that the patients feared being labeled “difficult”, and that they felt pressure to defer to the physician.

What’s going on here? It would be interesting to have the researchers actually watch the actual doctor visit to identify any of the doctors’ behaviors that are making patients feel reticent to speak up. Are doctors so rushed that they brusquely close the conversation? Are older patients simply deferring to the doctor because that’s how they were raised even though younger doctors encourage dialogue?

Thinking about this made me terribly self-conscious. Am I scaring my patients from asking questions? My patients ask lots of questions. Are they afraid to suggest treatment alternatives? They email me all the time me about treatment alternatives that they discovered on the internet or from their extremely well-meaning and knowledgeable neighbor. I always take their questions seriously. Am I authoritarian? I am opinionated, but I hope I always leave the final decision about treatment to the patient, and I hope even when arguing against a proposed treatment plan I do so respectfully.

Of course, I realize that humans are self-delusional creatures, so perhaps I’m just fooling myself. Perhaps I’m only thinking of the few assertive patients who dare dialogue with me while the rest cower beneath my raging authoritarianism.

So I suppose the best I can do is use this post as an open letter to any frightened patients who yearn to have a conversation with their doctor, but dare not. Speak up! If your doctor doesn’t listen, you need a different doctor.

Learn more:

Afraid to Speak Up at the Doctor’s Office (Well, the NY Times health blog)
Are you afraid to talk to your doctor? (CNN Health)
Authoritarian Physicians And Patients’ Fear Of Being Labeled ‘Difficult’ Among Key Obstacles To Shared Decision Making (Health Affairs, abstract available without subscription)