Gawande starts off by explaining the paternalistic approach where clinicians aim is to ensure that their patients receive treatment based on what is best for them. He says that clinicians have the knowledge and experiences to make these critical choices for their patient. To explain this approach, he points out an interesting example. He says that if there was a red pill and a blue pill capable of treating a patient, the clinician would tell the patient to take the red pill because it would be good for them. The clinician may or may not tell their patient about the blue pill; therefore, they tell the patient what they believe their patient needs to know. Gawande says that this is primarily the “doctor-knows best model” which is still a common approach used especially with vulnerable patients. However, the informative approach involves the clinician telling the patient everything they need to know such as the facts and figures and then they will leave the decision up to the patient regarding their treatment and overall health. For example, the clinician will tell the patient about what the red and blue pill does and will leave it up to the patient to make the decision regarding which pill they want to take. This approach can work because it allows patients to get only the tests, medications, and procedures they want according to their will and preference.
Personally, I see myself using the informative approach. I see myself providing patients with all the options in terms of treatment and the details regarding the medical interventions and then having them decide what he or she wants. I believe that with this approach, I have informed the patient of their disease state, the possible interventions, the risks and benefits, and filled in any gaps and doubts in their own knowledge. I believe it’s important for patients to know all of the medical information relevant to their disease, while still realizing what is important to them and their values. As a future PA, after telling my patients everything they will need to know, I hope that patients will make confident and sensible decisions. While I strongly believe my approach would be informative, I am aware that I will face challenges with this approach. One challenge I will face is that while being the informative PA, there will be times when I will catch myself following the paternalistic approach.
For example, Gawande talked about the neurosurgeon at his hospital using the paternalistic approach by saying surgery was his father’s best choice and that he needed to have it right now, but he also had to be informative about the details and options. While being informative, this in turn, increased his father’s fears and anxieties about what he wanted to do in terms of his treatment. As a result, this can put clinicians in awkward and tough situations. Lastly, with the informative approach, I will have patients who will want all of the information so they can make the decision that is best for them, but will still have no idea what they want to do; therefore, the decision comes back to the clinician. If I was put in this position, it would definitely be tough because I would need to find ways to inform what I think is best for them without going against their wishes and values. If the patient was still doubtful about their choice and mine, this would create a complicated and hard situation. I know there will be many times when we will hit a road block as clinicians with our patients; therefore, patience and remaining nonjudgmental will be critical.
Choose one specific chapter/people/stories that most surprised you or challenged your previous ways of thinking. Share the specifics on such.
In the chapter “Letting go,” Gawande introduced hospice care. He was doing his rounds with a hospice nurse named Sarah Creed, where he met one of her patients named, Lee Cox. Cox’s health was going down hill with congestive heart failure and pulmonary fibrosis. While her doctors tried slowing the disease down with medication, it didn’t work, and she continued to decline in her health. Cox accepted hospice care and moved in with her niece for support. I wasn’t surprised when the doctors thought she would only live for three weeks because in their eyes she was too sick to live any longer. However, Cox made it past a year with hospice care and I remember feeling shocked and happy as I was reading through her story. Gawande explained what he thought his goal for hospice care was which was letting nature take its course for the patients. I found myself relating to his view regarding hospice care and its goal for their patients. But, when Creed explained to him that hospice care was about helping people with an illness, living their lives to the fullest, and freeing them from pain, my original way of thinking was challenged. With supportive hospice therapy, Cox was able to live longer than her doctors thought. Also, the story of Dave Galloway who had pancreatic cancer, but then decided to go home with his family and do hospice care, helped me realize how important it is for patients to not only die happy, but to also live their lives to their fullest. Galloway passed away, but he died happy with the memory of his family at home. Similar to Gawande, I thought hospice care was just a place for dying patients where the patients knew their life was coming to an end. Creed’s idea that hospice care is about helping terminally ill patients live the rest of their lives happily, with loved ones, definitely challenged my original way of thinking for the better. I know that my new perspective will help me become a better physician assistant in the future.
Dr. Gawande wrote about a variety of topics, within this small book. Which of those, would you say most moved you and why? How do you see this impacting your future practice, if at all?
The chapter “A Better Life” was a memorable chapter because Gawande spends time explaining that people need to be needed. One of the most touching examples was when Bill Thomas took a new job as a medical director of the Chase Memorial Nursing Home, where he introduced 100 birds, four dogs, two cats, a colony of rabbits, and a flock of laying hens in addition to hundreds of indoor plants and a thriving vegetable and flower garden. This idea was brought up in order to improve, refresh, and stimulate his residents’ lives.
The part that moved me the most was that his experiment worked. In the book it was mentioned that the number of prescriptions required per resident decreased, psychotropic drugs for agitation decreased, total drug costs fell, and deaths fell 15%. Personally, I was inspired because it wasn’t that having a reason to live could reduce these rates for the residents, but it was the fact that these additions to the nursing home provided them with a reason to live. Thomas mentioned that people who thought they couldn’t speak began to speak and those who were isolated and nonambulatory started coming to the nurses’ station and showing interest in taking care of the dogs. Today, clinicians focus on fixing health with treatment and medication, but it’s important to recognize that people want to be needed and that we need to avoid making sickness and old age for the elderly worse. If professionals and institutions recognized this idea and put steps towards making this better, this issue could be changed.
In the future, as a physician assistant, we will be offering many treatments which require patients to sacrifice the now in order to enable better health in the future, for example, surgery or chemotherapy treatments for cancer. We also have the ability to sustain life for our patients, for example, through dialysis or ventilators. At the same time, as clinicians we need to acknowledge the patient, recognize what is important to them and their values, and recognize the mechanisms that work to keep the human body functioning and well as a means rather an end. Likewise, acknowledging and understanding that our patients feel lonely, bored, or helpless when they’re in nursing homes, a hospital bed, or even suffering in their own homes is a step forward towards improving our patients lives. As a future PA, I will acknowledge these factors and always try my best to provide ways my patients can be independent, have company, and living things to tend too. Simply, just being empathetic and understanding that patient’s want to feel needed and then doing our best as clinicians to make sure they are being provided care that offers this, is fundamental.