Some time ago, someone I know was going to have a fairly risky surgical procedure. Before the procedure, he had had a conversation about the risks involved. This is shared decision-making the Polish style.
Before I continue, I want to make one of my usual reservations. I don’t know what happened. I have a story of how the conversation went, how it was received, all that in the way it was remembered. It’s important because it’s always worth remembering, particularly, if you are a clinician, that just because you say something, doesn’t mean that I receive it even close to how you meant it. I also have no knowledge how typical such a conversation is.
Let me start by saying that the patient had been asked to see the doctor in charge for a conversation about risk. This framing of the conversation is significant as it tells us something not only about how such conversations are constructed, but also about what the patient’s role is. By framing this entire situation as ‘a conversation about risk’ reduces what is a complex situation where whatever decision is taken is way beyond simply assessing risk. Even commonsensically, deciding on a procedure, however risky, must involve at least some thinking of what life would be like without it and after it. Well, it seems that the idea has not dawned on (at least some) Polish medics, yet.
Interestingly, the conversation about risk turned out to be a conversation about risk. I was told that the medical team went for the ‘shock and awe’ option. There was no ‘team talk’, there was only risk talk. Right at the beginning of the conversation, the patient was told:
- If X happens, we will not be able save you, you will die.
- If Y happens, we will not be able to save you, either, and you will die.
- The chance of either happening is about X per cent.
The ‘shock and awe’ strategy went like a dream. The patient got shocked and awed, as the percentage quoted was scary. And yet, the lead medic decided to go with scaring the patient. Though, obviously, I don’t know what their intention was, any competent language user will understand that if you predict a death and the prediction is burdened with quite a high risk, the person you say that to is likely to be worried and/or scared. Even James Bond might have a flutter or two in the stomach. And I started wondering what exactly had been achieved communicatively.
The first aspect of the conversation is that, I think, it is part of what could be seen as the medical-actuarial model of illness/disease. Illness can be reduced to a biological fault that medicine rectifies. Medic is a glorified car mechanic who fixes things that go wrong. Much as you can replace a wheel, a faulty radiator or a shock absorber, you can replace a heart valve or remove the appendix. Yes, putting a stent in your coronary system is a bit more complex than putting a patch on your flat tyre, the foundation of the process, however, is similar.
The second aspect is the risk. It doesn’t matter if you’re scared or not, you must assess the risk which is represented in percentage. And the risk is represented not as your chance to survive (say, 80 per cent) but as your chance to die (20 per cent). Is it because, in the age of outcomes, presumably the ‘death outcome’ is what needs to be avoided? It’s also worth saying that risk in terms of percentages is never explained
This is medicine at its most dehumanised. I either have the skills to fix you or I don’t, your body is either fixable or not. Nothing else seems to matter. In this understanding of medicine, the fact that the patient is scared, doesn’t matter. What matters is that they evaluate the risk and take the decision how to proceed.
And so, the question that I wanted to ask: “what’s the point of scaring the patient?” seems not to arise. The patient’s fear is not even a blip on medicine’s radar. So, when I started concluding that anyone who’s about to have a life-changing and probably life-saving procedure understands that they’re ill and things are serious, I quickly decided that it didn’t matter. The point is different. The point is to say: your body is broken, we can fix it, this is what’s involved, this is how likely it is that we’re going to be successful. Quickly decide whether you’re in or out.
Yet, there is more here, I think. This is because after the hard-hitting beginning, the medic started softening the message, some additional circumstances appeared and from stark and very scary, things became somewhat better. So, perhaps, the question why scare someone is not completely irrelevant.
I started thinking that there is something quite narcissistic in one’s ability to scare the patient witless. Such talk allows you construct yourself as truly working right on the edge of experience. You know, you are not really a car mechanic, you don’t just change a gearbox. You deal with life and death, and that’s just before lunch. My life is truly in your hands (to quote the title of a doctor’s famous book) and you did just rub it in. Thank you so much, doctor. I am in endless debt….
As for the patient, the patient asked only one question. Significantly, no one thought to tell them whether they would get better. You know, if I am to go under the knife with a significant chance of dying, I would like to know whether, if successful, my life will change. Will I be able to get my life back? Not a single medic thought it was important.
This post is about a clash of (virtual) answers to the famous question “What matters to you?”. For doctors, bodies and risk matter, for the patient, life matters. Go figure.