When Patient and Physician Disagree on Treatment

One challenge I face in medicine is how to discuss areas of disagreement with patients. Recently, I had a gentleman come in to discuss some labs ordered by his naturopathic provider. The lab work indicated a disease process not supported by the current medical literature. Yet, he derived not only comfort from the diagnosis but also hope for treatment. He felt better on a treatment regimen that I considered suspect. He requested my review of his results and also support for the plan of care he selected. I chose my words carefully.

I believe that many non-traditional treatments and diagnostic tests arise out of our current lack of medical knowledge. We all see patients who hurt or feel bad or can't lose weight or are tired all the time. When faced with such discomfort, it is no wonder that they seek care and cure anywhere they can find it. However, I also ascribe to the scientific method and a certain code of ethics that cautions me to first do no harm. While I frequently prescribe herbal therapies, vitamin or mineral supplementation, and all types of lifestyle changes, these recommendations are still based on our best scientific understanding, and I provide full disclosure to patients about the limits of knowledge for certain treatments.

However, there are some so-called disease entities for which I am hard pressed to support treatment. Discussing these conditions with patients is tricky, because I am still their doctor and still care about them and still want them to feel healthy. However, I cannot honestly say that the evidence upon which I base my medical science supports the treatment they have selected. Choosing words that balance my respect for them as people with my lack of belief in some of the ways they've selected to receive treatment forces me to provide honest but kind feedback. Yet I feel frustrated, as I am sure my patients do, by our inability to find common ground on firmly held viewpoints.

A weary patient came in for an urgent afternoon visit last week, opening with the words, “I don't want to waste your time,” and proceeded to share a series of medical misadventures and poor experiences. The conditions for which the patient sought treatment were far more complex than I could address, yet at the end of the visit he thanked me for listening, telling me that I salvaged his bad day. This is what I always seek to provide: a therapeutic interaction. However, I often seek it in the certainty of medical knowledge and behind the veneer of science.

Years ago, I was particularly challenged by an elderly patient who seemed to come in to see me only to deride Western medicine. She brought in reams of test results for things that seemed sketchy and fringe. At her request, I called her alternative provider. What I realized in speaking with this non-licensed provider was that the patient was just looking for a sympathetic ear. Unfortunately, what I provided was a scientifically sound argument that seemed to come from an indifferent heart.

Even with all of our experience and medical knowledge, we are so prone to fail our patients, because we neither listen well enough nor do we always do an adequate job of coming alongside someone and sharing their pain.