I wrote this article on SDM (Shared Decision Making), that talked about involving the patient in their medical treatment decisions. It lowers costs overall and increases patient satisfaction. Even less educated patients really appreciate being told they have a choice in their care. I thought it was a win-win. But then reality set it.

I recently have been confronted with a new reality. The Press-Ganey. For those of you that don't know what this is, it is a survey that administrators of hospitals use as gospel for who is the best hospital. It is all about customer satisfaction. I've always practiced that educating your patients in the ER is the best medicine. Whether on nutrition or the nature of their disease process, my patients always appreciate it. Or so I thought. Now I'm being told that my patients don't want to hear that. They don't want to be told to quit smoking. They don't want to be told that it is best to have a primary care physician as opposed to the ER - even when I refer them to a free clinic for the uninsured. They want that prescription for a z-pack. They want their vicodin. They want that head CT or that MRI and especially that foot xray for that stubbed toe.

If you address their "real" needs and try to address their real issues, you get bad reviews (i.e. Telling patients that you are giving them imitrex for their headache as it is a much better migraine medicine than demerol, and neurologist recommend not giving opiods unless nothing else works, does not make you popular). If you ignore the necessary education and simply give them the prescription they want, you get good reviews. Is this the best way of practicing medicine? According to administrators, we should continue our good practice of medicine, and address our patients wants and needs. Unfortunately, these don't always line up.

I get that the patient has a say, and in that say, they determine that they don't want to hear your doctor advice. They are there for a purpose. Anything else is irrelevant. I don't subscribe to the paternalist view that everything the doctor says is the only way. But sometimes what helps you is not what you wanted to hear, but what you needed to hear. And if I am being told to stop trying to help my patients understand their disease, and improve their disease and even PREVENT their disease - then what good is SDM? What good is Press-Ganey? What good is customer satisfaction?

I was all over the neat idea of SDM a few weeks ago. Now I am thinking that paternalistic measures weren't such a bad thing after all. If patients have a right to dictate their care, even if it is not in their best interest, what then is my purpose?

I welcome discussion on this topic.