As students and health care providers, we are tasked with offering patients medical advice based on screening guidelines. As scientists, it is our duty to provide evidence based, quality recommendations related to patient care.
In a primary care office, screening for disease and prevention of complication remains paramount. The conversations we have with patients are aimed to steer them toward a decision. From Pap smears to colonoscopies, testicular exams to mammograms, the conversations we have with patients help shape their health decisions.
Classically, the paternalistic approach to medicine was one where clinicians told patients what to do. They presented patients with the facts regarding a procedure, surgery, or screening method and then told the patient when it would happen.
As medicine has evolved, this method of clinician interaction has faded. The concept of shared decision making, where a clinician and patient sit together and review all of the potential risks, harms, and benefits to a procedure or screening intervention has won out.
With this method, friction arises between clinician and patient. How do we respond when a patient refuses a screening test? How should we act when a patient with cholesterol of over 300 refuses a statin? How about the patient who, despite a family history of breast cancer, refuses all mammograms? It can be frustrating and challenging, but at the end of the day, the patient makes their own health decisions.
In my experience, I have met patients who display various rationale for their decision making. Some patients will respond with a classic, “I’ll do whatever you tell me to do”. Other patients require motivational interviewing, discussion of risks, benefits to every test. Some patients require a few minutes of coaching over a period of many visits, but ultimately decide to comply with screening guidelines.
Still, there is the patient who despite all technique, all logical, evidence based care guidelines, refuses to comply with screening. Again, there are many approaches to conversation. Sometimes educating patients on the consequences of not screening such as a late stage cancer may help compliance. Other times, simply asking “why not” may elucidate a fear that can be quelled.
I can still recall the first time I was involved in the consequences of not screening. As a new provider, I had been taking many new patients. Some patients came with many pages of previous medical records, others came with none.
This particular patient’s medical history was very simple and can be summed up in one sentence. “I was born in a hospital; I have never had any problems until I started losing weight a few months ago”.
Our relationship lasted all of four weeks. It was one of those visits that with each question, my heart sank deeper. There was no time for discussion of colonoscopies, lipid panels, or prevention of diabetes. Time was not on our side.
In quick succession, a history and physical revealed significant cause for concern via hepatomegaly, cachexia, and multiple “red flag” concerns. Basic lab work showed significant electrolyte abnormalities, startling inflammatory markers, and iron deficiency anemia. A subsequent CT scan of the abdomen showed tumors “too numerous to count”, thought to be from an adenocarcinoma of the colon with metastasis in multiple places.
It’s the kind of patient encounter you dread from the moment you realize it will occur. The conversation stems from shock, to fear, to anger, to every emotion in between. The thought was that the colon cancer had been present for quite some time and had progressed beyond the point of no return. Despite an urgent oncology consult, there was nothing to be done.
This patient comes to mind often. I am forced to wonder what the conversation would have been had our paths crossed sooner. Would the concept of a colonoscopy have been a simple conversation? Would it have taken a little bit of convincing on my part? Or, would the outcome presented above have been unchanged?
Some questions in health care remain unanswered. But, as clinicians we must take an opportunity to learn from each experience that comes our way. This case comes to mind frequently. Very often, I will have a patient who despite all techniques, motivators, evidence, will adamantly decline a particular screening test. Occasionally, as a last ditch effort, I will tell a story of missed opportunity, heart ache, and lessons learned.
Sometimes it is successful, sometimes it is not. The patient may agree to move forward, or may stand with their decision. As health care providers, we must respect this. The health care decision made is the patient’s, and despite what we personally would do or recommend a family member to do, the patient will live with the decision.
Recently, a patient came back in for follow up after missing an appointment or two. The patient previously had declined most screenings. As we chatted about the changes in the patient’s health, an almost “by the way” comment arose. At the close of the visit, the patient casually said, “I ended up getting that colonoscopy a few months after we talked. The doc said that there were three polyps that weren’t cancer now, but would have been in 5 years!” With that, the patient stood up and went to check out.
So much of what we do in health care has become so routine and may no longer resonate with us. In this case, a conversation about a colonoscopy during a jam packed, acute visit prevents a much different type of conversation years down the line. The simple conversations we have each day with patients may not seem of great consequence to the present, but are of extreme consequence to the conversations they allow us to avoid in the future.
This article, blog, or podcast should not be used in any legal capacity whatsoever, including but not limited to establishing standard of care in a legal sense or as a basis of expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the podcast or blog.