Real choices: what real world shared decision-making can be like

Crossposted to Talking To Your Doctor.

I used to be a snob about people who didn’t vote because they couldn’t see themselves picking any of the available candidates. “But that’s your responsibility!” I would say to myself, self-righteously.

Thomas Hobson.

Then I became a doctor, and I began to realize that we provided these non-choices to patients all the time. Like today, for instance, when I asked a patient permission to refer her to gastroenterology for her fecal incontinence. (At least we talked about it – because she brought it up. Often times people don’t do even that much, a fact I discuss in my book reflective of the broader reluctance of patients, and sometimes doctors, to discuss sensitive issues.)

I asked, “Is that okay with you?”

Which is BS, really. I suppose it’s better than making the referral without discussing it with the person at all, but there’s no choice there. Even if I were to break down the possible alternatives – refer; take care of the problem just the two of us, me and the patient; kick the can of the problem down the road – how is the patient supposed to know what might be preferable? Heck, I’m not sure I even know.

This is what makes real-world shared decision-making so complicated. I don’t know what fraction of medical decisions are like the one above, but certainly a big chunk are. When the doctor doesn’t know what the right answer is, and the patient doesn’t know enough to have a clear preference (or no clear preference is possible), what can really be shared, after all?