The difficulty of medical decision-making: should patients be involved?
Introduction
The success or failure of treatment has long been attributed to the doctors alone, but the role of patients in the medical decision-making (MDM) process has often been ignored. As medical development and health needs increase, the desire of patients to participate in MDM continues to grow. This raises the question: should patients be involved in such a highly professional medical activity? How can their involvement bring better clinical benefits?
Tailor-made approaches for different disease cases: patient involvement in MDM should not be generalized
We must acknowledge that in the current healthcare environment, it is unrealistic to fully involve patients in MDM due to objective conditions such as limited medical resources. Such involvement could inevitably slow down the pace of medical treatment and threaten timely treatment in some acute diseases. However, exclusion of patients from MDM is contrary to the course of medical development (1) Currently, our MDM model should not be generalized but tailored to different cases, with the degree of patient involvement determined based on the nature of the disease.
In our multidisciplinary treatment (MDT) for difficult hepatobiliary and pancreatic diseases, patients are involved throughout the process. We have found that encouraging patients to participate in MDM in difficult cases could help to improve the efficiency of doctor-patient communication, the patients’ trust in the medical team, and their compliance with treatment plans.
Taking end-stage liver disease as an example, liver transplantation (LT) is currently the only curative treatment (2). Patients have high expectations for this treatment as well as doubts and concerns. Although LT is relatively mature, there are still risks involved, and long-term postoperative management is required. Therefore, we always communicate with patients before LT through MDT and other methods to help them form a correct understanding of the disease and the surgical plan. We jointly develop personalized treatment plans with patients, and that helps them better understand the benefits and risks of the surgery, which makes it easier for patients to make decisions and cooperate with the transplant team.
In clinical practice, there are some patients who need to receive living donor LT. In this scenario, the donor is a healthy person receiving organ donation surgery, which presents great physical and psychological challenge; at the same time, the doctors face pressure from both the donor and the recipient, and may encounter difficulties in moving forward with the surgery. In the case of an older brother donating part of his liver to his younger brother, the older brother and his relatives (such as his wife) should also be included in the MDM, encouraged to fully express their expectations and preferences, and to take into account their financial, cultural, religious, family, age and the disease condition, in order to decide whether to donate and to determine the best surgery plan. The joint participation of both donors and recipients in MDM helps them to reach a consensus based on a full understanding of the benefits and risks of the surgery; on the other hand, the understanding and support of the patient can give transplant surgeons more confidence.
For difficult cases, we actively seek the patient’s involvement in MDM to the extent possible without violating medical treatment standards, in order to give the greatest respect to their right to life and health. However, for some common or frequently occurring diseases, such as benign conditions like cholecystitis, the corresponding treatment protocols are often well established and can generally achieve good results (3). For these patients, MDM can be led by the doctors based on routine informed consent, without overemphasizing the involvement of patients, which can also avoid their unnecessary doubts.
The game of rights between doctors and patients: the right to lead vs. the right to participate
MDM is a highly specialized medical activity. However, most patients do not have the same level of medical knowledge and clinical experience as doctors. Therefore, we must determine the extent to which patients participate in MDM. Overemphasizing patients’ participation may lead to unexpected outcomes.
The unrestricted development of the internet has amplified medical disputes, as some patients are easily influenced by negative reports and thus misunderstand doctors, preferring to trust the information they find on the internet rather than professional suggestions from doctors, and may even “demand” doctors to treat them according to their own ideas. While we can understand to some extent the unreasonable behavior of these patients, it often undermines standardized care and may result in poor prognosis.
On the other hand, if the doctor caters to the unreasonable demands of the patient and lose their initiative, even under the “influence” of the patient to administer treatment that is not in line with medical norms, it is actually an irresponsible behavior that violates the patient’s right to life and health, as well as a violation of their own professional values and medical spirit.
The arrogation of rights between doctors and patients can lead to undesirable outcomes and exacerbate their conflicts. Therefore, it is necessary to carefully define the attribution of the “right to lead” and “the right to participate” between doctors and patients. MDM, as a professional medical activity, should be dominated by doctors, meaning that they are primary responsible for the development of treatment plan, while the patients have the right to participate, that is, after informing the doctors of their condition, they should receive feedback and make the final choice for the treatment plan given. Doctors and patients each have a role and should respect each other’s rights in MDM.
Keeping up with the times: exploring new models of MDM in the age of artificial intelligence
In fact, we encourage patients to participate in MDM, as it helps to improve their satisfaction with medical services and promotes a harmonious doctor-patient relationship. However, in clinical practice, we often encounter situations where some patients are unwilling to participate in MDM on the grounds that they do not understand medicine or do not want to bear the medical consequences. On the contrary, some patients who lack medical knowledge insist on “commanding” better treatments, which leaves doctors helpless. The unequal distribution of medical knowledge between doctors and patients creates information barriers that need to be broken down.
Fortunately, rapidly evolving artificial intelligence provides us with hope to solve the above problem. One promising example that has garnered public attention is the chatbot program ChatGPT. It is important to note that ChatGPT is not a professional tool and the accuracy and timeliness of its medical knowledge still need to be improved. However, the medical community has long been working on developing such tools, including clinical decision support systems (CDSS) designed for doctors and patient decision aids (PDA) designed for patients. These tools aim to promote efficient information exchange between doctors and patients and help patients acquire disease knowledge. Studies have shown that these tools are effective in improving medical quality, patient compliance, and service satisfaction (4,5).
These tools are expected to bridge the gap in disease knowledge between doctors and patients, empowering patients to participate in MDM in a more informed manner. However, due to the gravity of the medical discipline and the constant updates in medical knowledge, the widespread implementation and application of such tools require further practical testing and continuous optimization. Especially in China, where related research started relatively late, there is still a long way to go before these tools can truly become commonplace.
Conclusion: building a harmonious community of shared destiny between doctors and patients
With the continuous development of human civilization and medicine, there is a trend toward greater patients’ participation in MDM. We should realize that doctors and patients are always on the same side in the face of diseases. Encouraging and guiding patients to be more involved in MDM is not only a reflection of medical humanism and professional values, but also a higher demand from patients in this era. To make this work, doctors and patients must clearly define their rights and responsibilities in MDM and work together with mutual respect and cooperation. However, despite the trend toward shared decision-making, we still lack the necessary conditions to fully implement this approach. It will require the support of relevant policies and laws, the advocacy of medical institutions, the positive response of doctors, the participation of patients, and the assistance of professional tools (6). Transforming MDM models is essential to create a harmonious doctor-patient community of shared destiny in this new era, which require the joint efforts of all medical professionals and participants in our medical-related industry.
Acknowledgments
Funding: None.
Footnote
Provenance and Peer Review: This article was commissioned by the editorial office, Hepatobiliary Surgery and Nutrition. The article did not undergo external peer review.
Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-23-245/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
References
- China Youth Daily. Experiment on doctor-patient relationship by three academicians. Available online: http://zqb.cyol.com/html/2015-06/24/nw.D110000zgqnb_20150624_1-12.htm
- Ling S, Jiang G, Que Q, et al. Liver transplantation in patients with liver failure: Twenty years of experience from China. Liver Int 2022;42:2110-6. [Crossref] [PubMed]
- Gallaher JR, Charles A. Acute Cholecystitis: A Review. JAMA 2022;327:965-75. [Crossref] [PubMed]
- Agoritsas T, Heen AF, Brandt L, et al. Decision aids that really promote shared decision making: the pace quickens. BMJ 2015;350:g7624. [Crossref] [PubMed]
- Graber ML. Reaching 95%: decision support tools are the surest way to improve diagnosis now. BMJ Qual Saf 2022;31:415-8. [Crossref] [PubMed]
- Yu SF, Wang YY, Deng T, et al. Medical decision-making series 1: development of shared decision-making at home and abroad. Med Recapitulate 2020;30:159-67.
