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Patients at the centre: in our practice, and in our use of language
  1. Gordon Guyatt, MD,
  2. Victor Montori, MD,
  3. P J Devereaux, MD,
  4. Holger Schünemann, MD,
  5. Mohit Bhandari, MD
  1. Departments of Medicine and Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada

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    In a formerly widespread approach to medical decision making, physicians made a diagnosis, considered the management alternatives, and informed patients what would be done to help them. Decision making rested exclusively in the physicians’ domain.

    This parental model of patient care challenged clinicians to interpret what was best for their patients. How much benefit must a treatment offer before it was worth subjecting a patient to its short term side effects, long term risks, inconveniences, and costs? With the clinician at the centre of decision making, the question was whether a treatment effect was “clinically relevant.” Even in the discipline of health related quality of life measurement, investigators sought the “minimal clinically important difference.”

    The parental model has its strengths, and in the past it is very likely that many patients preferred leaving the decisions to their doctors, particularly when the knowledge gap between physicians and the lay public was greater. Consider, for instance, the results of a survey of 2472 patients with chronic disease (hypertension, diabetes, heart failure, myocardial infarction, or depression) completed between 1986 and 1990. In response to the statement: “I prefer to leave decisions about my medical care up to my doctor,” 17.1% strongly agreed, 45.5% agreed, 11.1% were uncertain, 22.5% disagreed, and only 4.8% strongly disagreed.1 Cultural changes since the 1950s suggest that in the more distant past, the percentage preferring to leave decisions up to the doctor was even greater. For example, in the survey that generated these data, older patients were less inclined to prefer an active decision making role than younger respondents.

    Parental approaches to decision making have limitations related to physicians’ evaluation of how patients value benefits and risks. One issue is physicians’ tendency to assume that physiological outcomes will lead to improvements in mortality …

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