Just elaborating (nitpicking?) on this point a little bit. One of the key points about being a fallible person and doing your best is that you admit the fallibility and strive to improve yourself.

In a case like this – that means reading the complaint for comprehension, admitting you were wrong, and apologising for real (not a sulky “oh gee, I’m sorry you were offended” faux-apology, which appears to be what occurred, filling in the gaps in the media reports).

If you refuse to do these things when the initial complaint occurs, and insist on pushing your own barrow of hubris to the point of external involvement – then you suck it up and go along to the prescribed medical ethics class, or whatever other action is appropriate to reduce the chances of the error happening again. You don’t bluster around clumsily defending your actions and lambasting ethics education as “touchy-feely school” – these aren’t the actions of someone who believes in the autonomous model.

Great blog, Kevin. Thanks.

I think you’re right in all this.

Autonomy does put a great deal of responsibility on the patients. If patients control the treatment encounter because they know their own values and goals best, and treatment providers are required to act in keeping with those values, then the patients must communicate those values and goals to the providers to get the right kind of treatment – there’s no other way for the providers to proceed. And patients must also accept that there will inevitably be miscommunications and providers will not be able to give them what they, the patients, want – as opposed to the “doctor knows best” model in which we can hold providers completely accountable for all missteps because the providers define the appropriate treatment and completely control the patient encounter.

However:

If it has been your experience that being assertive and aggressive is often a good way of prodding certain patients to examine their priorities and come to terms with their health, then you might feel a duty to be assertive and aggressive.

This seems to me to be a move back toward the ommipotent-provider model. The goal of the provider is not necessarily to “prod patients to examine their priorities”. The patient may be perfectly happy with their priorities, and have already come to terms with the state of their health (this is what the “fat acceptance” movement is all about). The provider’s role under the autonomy model is to provide the patient with the information and treatment alternatives that are relevant given the patient’s priorities and state of health, and assist the patient in making reasonable choices by the patient’s own lights, and then providing the chosen treatment. It’s almost never necessary to be overly aggressive to convince patients to accept and live by their own values, so getting heavy-handed with patients while playing this kind of provider role seems strange. (And that seems clearly not to be the way this doctor visualizes his role.)

Good points, though. Thanks for your comments.

And I agree with you that doctors should respect a patient’s autonomy.

But it seems to me you are leaving something out of the equation here: the patient’s role in this whole autonomy model of the doctor/patient relationship.

Pretend you are a doctor.

You not only have a duty to respond to a particular complaint that a patient volunteers. You also have a duty to take a thorough history and, with the consent of the patient, to conduct a thorough physical exam whenever such an exam is indicated.

If you uncover a condition, such as diabetes, high blood pressure, or chronic obesity, that is health-impairing or life-threatening, you have a duty to inform and educate your patient about the condition and about what can be done.

If it has been your experience that being assertive and aggressive is often a good way of prodding certain patients to examine their priorities and come to terms with their health, then you might feel a duty to be assertive and aggressive. While you know it is easy to go a little bit too far if you choose to be assertive, you decide that the benefits to such an approach far outweigh the costs, such as hurting a patient’s feelings.

Let’s assume, however, that you are wrong. Let’s assume that you have misinterpreted your experience, and your approach, on balance, has in fact been counterproductive.

And let’s say an obese patient comes in and gets the obnoxious lecture treatment from you. What should the patient do?

Should she ignore your advice, and pretty much continue to not address her obesity? Should she sue you, despite the fact that patients are autonomous and are free to ignore any particular doctor and get another opinion? Should she resent you and your advice, despite the fact that you are just a fallible person doing the best you can, as you see it, to perform your duty?

I think if we take the autonomous patient model seriously, then along with the rights you describe there are also certain responsibilities. A patient should expect that a trip to the doctor’s office might entail some unpleasant surprises. A patient should deal with a poor bedside manner not by playing the victim, but by engaging in constructive feedback (unless, of course, the doctor is guilty of serious abuse). And ideally, a patient should be grateful for unpleasant information that is helpful, even if the doctor delivers it in a somewhat incompetent fashion.

In other words, autonomy is a two-way street. If patients are free to make mistakes regarding their health, then doctors should be free to make well-meaning errors in trying to educate their patients.