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Dr. Informative vs. Dr. Knows-Best

Tags:: Article Medical Ethics

Last week, I completed my note about Cerebellopontine Angle (CPA) Tumor where I read a fascinating treatment option: observation. Since 85% of CPA tumors are benign, observation became an option. Doing nothing but watch it slowly grows. From a palliative perspective, this makes sense. In fact, it relates to what Atul Gawande observed about what does it mean to be either Dr. Informative or Dr. Knows-Best (Paternalistic model).

Bob Arnold, a palliative care physician I’d met from the University of Pittsburgh, had explained to me that the mistake clinicians make in these situations is that they see their task as just supplying cognitive information—hard, cold facts and descriptions. They want to be Dr. Informative. But it’s the meaning behind the information that people are looking for more than the facts. The best way to convey meaning is to tell people what the information means to you yourself, he said. And he gave me three words to use to do that. “I am worried,” I told Douglass. The tumor was still there, I explained, and I was worried the blockage was likely to come back. (Location 2658)

Dr. Informative assumes that their task is just supplying cognitive information. Dr. Knows-Best 'attacks' the patient with their preferred treatment option, not asking their patient what they want. As our identity is sticky with our capability, as a clinician we boast on our knowledge. But, our patient does not need that. People are looking for the meaning behind the information, not the cold medical facts or statistics. It is not wrong to be highly informed and smart but in our relation to patients, but their desires need to be appraised.

I realized, with shame, that I’d reverted to being Dr. Informative—here are the facts and figures; what do you want to do? So I stepped back and asked the questions I’d asked my father: What were her biggest fears and concerns? What goals were most important to her? What tradeoffs was she willing to make, and what ones was she not? (Location 3024)

The all knowing God-like figure that tells the patients what they should do and does not discuss options that the doctor does not think are optimal

Second-order desires

Suppose one person is a smoker. He desires to smoke a cigarette. But he also desires not to desire cigarette again.

In the hospital, your patient desires to make a right judgment about their treatment. They also desire other things, perhaps, not feeling nauseous from the treatment.

As a doctor, we need to remember this when we provide our patients with facts. What do they want? What do they want to achieve? What is their target? What's important for them? In my practice, I noticed doctors rarely ask things besides anything unrelated to their history & physical. We assume they know our decision is the best for the patient. We assume they believe in the same thing as we do. We assume we know the best. Yes, Dr. Knows-Best.

Where do you see yourself as a doctor? More into Dr. Informative or Dr. Knows-Best?

While both has its own advantage, seeking the balance is always the greatest choice.

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Dr. Informative vs. Dr. Knows-Best