Christopher Ryan: Beware the smiling nod

HOW often do your patients disagree with you? Would you even know if they did?

US research published recently in the Archives of Internal Medicine suggests that the answer to the second question is “no”.

Researchers surveyed an online panel of 1340 patients who had recently seen a physician. The patients, most aged between 40 and 60 years, were asked to read a hypothetical scenario about the treatment of heart disease.

The scenario included a range of health care decisions, none of which, apparently, was objectively the best. The researchers claimed that the choices would depend, not on science, but on the doctor’s and the patient’s preferences and values.

Surprisingly, while almost all patients could envisage asking questions and discussing their preferences, only 14% said they would voice disagreement if their preferences conflicted with their doctor’s recommendations.

Among those who’d keep schtum, around half were worried they’d be labelled a “difficult patient” and half worried that dissent might stop them getting proper care. Only 14% of respondents thought that it was “socially acceptable” to disagree with their doctor and only 15% thought that a disagreement would end well.

These are worrying results. Even if you generally adopt a doctor-knows-best attitude, these were decisions where apparently the doctor didn’t know best. All the choices were a matter of personal choice.

Nonetheless the vast majority of patients would have simply smiled and nodded at the doctor’s stated preference.

What researchers didn’t ask, of course, is how many of the 86% who stayed silent would have actually done what the doctor was suggesting. I am guessing not too many.

What does this mean for Australian doctors? Well it’s hard to say.

First, this was an internet survey based on a hypothetical contact. It is hard to know exactly how the findings would translate into practice.

Second, the researchers didn’t actually specify what these “preference-sensitive” choices were, and it’s easy to imagine that these details might have influenced the results.

Third, these patients were highly educated, insured, often retired and mostly North American. To what extent are these patients like Australian patients?

On this last point at least, it is difficult to take much solace. They don’t sound like a population that will be unusually deferential to views of authority figures.

For me, the message from this study is simple. Until we get conflicting data from good Australian studies, I am going to assume that if I suggest some preference-sensitive health care option, most of my patients are going to smile and nod, regardless of what they think of my opinion.

That, of course, will make my life easier, but I doubt it will translate into their actually taking up that option.

That is probably not going to matter too much for preference-sensitive choices, but I’ll also assume that patients will do likewise for choices that are influenced by an evidence base.

More smiling and nodding. More not actually doing.

If I want patients to take up option “A” and they don’t even tell me they disagree, then I am not going to get much chance to convince them otherwise, and they’re likely to simply ignore my advice when they get home.

There is surprisingly little data on what we should do to counter this situation, but common sense dictates that it is best to let the patient voice their opinion on a choice before you voice yours.

If your opinion is different, try to understand the patient’s perspective, and if you still disagree, carefully put the opposing view, but all the while assure them that in the end the choice is theirs.

Reassure them that disagreeing won’t affect your opinion of them and that patients who disagree aren’t “difficult patients”, they’re the patients who make the job interesting and fun.

Dr Christopher Ryan is the director of consultation-liaison psychiatry at Sydney’s Westmead Hospital and an honorary associate of the University of Sydney’s Centre for Values, Ethics and Law in Medicine, where he is the program director of the mental health and psychiatry stream.

Posted 10 September 2012