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The Complexity of 21st Century Health Care

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Managing Dilemmas

All decisions that patients face are inevitable couched at least within dilemmas. Sometimes they are couched in nested dilemmas and at other times drop clear into the mystery zone.  Yet, the training that doctors get only made puzzles and problems in their scope of practice—so now what? Plenty of doctors still try to remove dilemma-thinking from the process.   “I operate on you next Thursday or you will die.”  That is a doctors attempt to remove dilemma-thinking and make a dilemma into a problem.  He/she is telescoping to the patient…..you do what I say, or you will die—so don’t think about your own views or what matters to you.  Don’t ask me questions about whether I’m any good at this operation or someone else might not agree with my recommendation.

It takes a healthy physician who has an ego that is no longer involved to state there are 5-6 ways to approach this particularly challenging and complex situation you find yourself in….

“Here are the 5 options most people choose and here is why I am recommending option #3 for you which takes into account X, Y, Z factors that are very important to you and A, B, C factors that are most important to me as your physician.   How would you like to proceed?  Oh, I see you actually favor option 4, well, here are some potential downsides I want to be sure you’ve thought about and why I didn’t pick that as top choice in your case.  Oh, you aren’t concerned about those downsides and still strongly prefer option 4, well, that is fantastic news and we can begin your course of treatment now, do you want me to talk to you sister so she is aware of the options and why we are following options 4?”

We suggest that there are at least two levels of dilemma.

Simple Dilemma

These are conditions when there are two opposing and equally weighted options. A simple dilemma in the clinical setting would be when the physician wants to focus on her top priority—prevention of coronary artery disease through lifestyle modification and medications—while the patient wants to focus on his top priority— consuming alcohol, Vicodin, valium, and tobacco to manage his nerves and chronic pain. It is not infrequent that the physician will reframe the dilemma presented by these opposing priorities by labelling the patient “the problem.”

Mis-framing in this way places a right/wrong or either/or choice where a better/same/worse and both/and choice belongs. In a right/wrong and either/or framework—with implied power difference between the physician and the patient being labelled as a “problem patient”—leads to a discussion of how lifestyle choices & medications chosen by the patient are impairing his coronary arteries and the dismissal of any notion of importance of pain management in keeping the patient more active and healthy overall.

Thus, rather than leveraging a dilemma through collaborative shared decision-making—the patient is left with a prescription he will not take for his cholesterol and the need to find an urgent care or emergency room to get a refill of his two medications he has been taking for 6 years from a prior physician. The physician is left believing she has helped assure a longer life for her patient and all she has achieved is to offload the patient’s care needs to another physician who may repeat her now codified approach of refusing to refill medications, lecturing the patient, and providing him a prescription he does not want nor will take. With enough of these events, he is labelled as “non-compliant” and might eventually be dismissed from the practice as “pain medicine seeking and non-compliant problem patient.” So, instead of a collaborative, engaged, shared decision-making process to leverage opportunities within a simple dilemma, we are left with a falsely “right” physician and a keenly dissatisfied and un-helped “patient” adrift.

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