Informed consent, medical ethics and more rambling

This is just gonna be me rambling some more.  Hopefully I can make some kind of sense here.  I just took some pain meds for my back, though, so if I don’t make much sense, blame it on that.

I’m real big on informed consent.  We all have the right to make our own choices about our health.  But in order to make the choice that is best for us, we need to have all the information.  If you go to your doctor and say you are having migraines and your doctor says, “Here is some medication.  It will keep you from getting migraines," you will probably decide to take the medication.  However, if your doctor says, “This medication often prevents migraines.  However, some people find it gives them nightmares," you might make a different decision.  It depends on how bad your migraines are and how much you hate having nightmares.  In order to make the best decision for you, you need all the facts.  And the best decision for you might not be the best decision for me.

And this is where I get bothered.  It seems like doctors often do not give patients all the facts.  When they don’t give us all the facts, and we agree to do whatever they suggest, that is not informed consent.  That is them trying to make decisions for us, which I find paternalistic and insulting.  Several years ago, when I went to see a doctor about my migraines and was offered a prescription to prevent them, I was not told that this drug sometimes causes nightmares.  I have PTSD and have nightmares often enough already.  I would not have taken the drug if I had known it might make that worse.  Apparently the doctor had decided that the medication was appropriate for me, despite knowing I had PTSD, but I disagree with her decision.  And it should not have been her decision to make, anyway.  It should have been my decision.

I think it is unethical for doctors to provide care to us without our informed consent.  It takes away our ability to make our own decisions.  It suggests they believe we aren’t smart enough to make good decisions for ourselves.  It’s very judgmental.

Here are a couple of WLS-related examples.

A couple of RNY folks have told me that their doctors recommend Flintstones for patients.  When they asked their doctors why they recommended a children’s vitamin that doesn’t even have all the nutrients we need in it, their doctors told them that they recommend Flintstones because it’s cheap and they believed their patients would be unwilling to spend the extra bucks for quality adult vitamins.  Now, never mind the fact that quality adult vitamins do not cost much more than Flintstones.  Look at all the assumptions in those doctors’ statements.  Apparently they believe all their patients are poverty-stricken or that they do not care enough about their health to spend a little bit more for good vitamins or that they are not intelligent enough to understand why they need good vitamins.  How judgmental is that?

Or there is the issue about some doctors telling patients that drinking soda will stretch their pouch.  There are a number of good reasons to avoid soda, but preventing the pouch from stretching is not one of them.  When doctors decide to try to scare us so we won’t drink soda because they have decided we should not drink it, that is preventing us from making an informed decision about the matter.  And it is judgmental.  It’s doctors deciding we are not smart enough to make the “right" decision by ourselves so they have to trick us into doing the right thing.

So, if you’re still reading, what are your thoughts?  How do you make sure you’re fully informed before you consent to treatment?  Do you have any ideas of how we might encourage doctors and other health care providers to get informed consent from patients before treating them?

REALLY GOOD POINTS, Kelly!

First off... I am one to do TONS of research on my own, regardless of what the doctors tell me. I have been across MANY occasions when the doctors are 100% inaccurate. It still boggles my mind how a board certified physician could be SOOO wrong about something medical?!?!

For some people, they probably think that "hey, this is a doctor who went to medical school.... I am going to trust them and do what they say..." >>> DO YOUR HOMEWORK!!!! Just because "in studies it works for most patients" does NOT mean it might work for you.

I guess my views are the same as yours, Kelly.... more so because I was selected as a Juror 2 years ago for a medical malpractice case!!! And my god, that opened my eyes!

Encouraging doctors? I don't know how that would happen...

I think it is easy to assume that doctors should know the answers to anything medical, but the truth is, no one can know everything.  And with new research on medical things coming out every day, how could one doctor keep up with everything?

But even when a doc knows the information, sometimes there's not one right answer to a question.  Like the problem I had with the migraine medication.  My doc was probably correct that the medication would keep me from having such awful migraines.  And some people would have been happy to try the medication and risk having nightmares.  There is really no way that even the smartest doctor could know whether or not I would feel the risk of increased nightmares was worth taking, though.  That's not something they could be taught in medical school.  As far as I know, no medical schools currently offer a course in Kelly.

IMHO--I think the Internet is the best thing to come along when it comes to medical info.
Yes, see a doctor; learn what he has to say; pay attention.  Share your concerns about his
considered opinion.  TALK to him/her.  I've been fired by a doctor for questioning him and
not taking his recommendations immediately.  OK, I go to another doctor *****spects
that I'm an adult.

I interview all the doctors I go see now.  I've moved more times than I care to remember
in the past four years, and ask each new doctor what their attitude is towards WLS.  I've
been pleasantly surprised at the respectful conideration I've been given, and I do
question their recommendations, and we have all been able to come to a good working
relationship.

Yes, some doctors give no consideration to the mental abilities of their patients;  that
is why I question them.  Works for me, because it's my body and my life, not theirs.

It's all "Practice", on their side as well as mine. I just recently had a PA ask if I were
a medical professional when we were discussing a medical problem I was having!

Be informed.  You know your own body best.  Pay attention, because that's why you
pay them.  Work together.

I interview all my health care providers too.  I think I can tell a lot about them just by their reaction to being interviewed.  If a doctor acts like he doesn't like being interviewed, I know that's not going to be the doc for me.

I've had doctors ask me if I was a medical professional too.  Once when my sister was pregnant I went to her OB with her and she was telling him how she wanted to avoid certain interventions when she was in labor and giving birth.  He was basically brushing her off.  She told him she did not want an IV and he tried to say she had to have one since she'd had a previous C-section.  If her previously operated on uterus should rupture during labor (very, very unlikely) he felt it would be very important to have a line already in.  So I asked, "Why can't she have a hep lock instead?"  He looked very surprised and asked if I was a nurse.  I said, "Nope.  And why can't she have a hep lock instead?"  And he agreed to the hep lock instead of the IV.  Of course, he should have offered that himself as an alternative.

I have more thoughts on this than I think anyone would want to read so I'll limit it to one. I don't necessarily think it's about informed consent, it's about time. Under the current health care constructs most providers only have 10-15 minutes max to interact with patients. In that time frame it's not really feasible to do a history, assessment, and cover all the possible side effects of medications except for some really big ones. Unfortunately, I often see than no side effects are mentioned and it's up to the patient to figure out what risks the meds have. Personally, I think this would change if we had a health care system that allowed doctors to spend more time with their patients and to actually know who they are. In my area of Northern Virginia, most family practice doctors have a load of 4-6,000 patients. How can you remember everything you need to know about someone and really help care for them when you have virtually no time and so many people to remember? It's impossible. As one doctor friend said to me recently, "it's not fair to me, and it's not fair to my patients but unless I follow the rules I won't get paid." I'm not sure how to change it to be honest. But I hope with health care reform we might see some improvement. My fingers are crossed, for all of us.

I agree that the time issue is important.  At the same time, though, I don't think it is a matter of doctors not be allowed to spend more time with patients.  I mean, if a doctor works for a specific company and that company has a rule about how much time he can spend with patients, then yeah, he's not allowed to spend more time.  But for doctors in private practice, at least, they are allowed to spend as much time as they want.  Most choose to spend as little time as possible in order to see as many patients as possible in order to earn as much money as possible.

Why wouldn't your doctor friend get paid if he spent more time with patients?  Does he mean he would not get paid, or does he mean he would not get paid as much?

I understand doctors have to make a living . So does everyone else.  Time is a factor in many businesses, it seems.  For instance, if I made my living cleaning houses, I could choose to spend four hours doing a really good job on a house or I could choose to spend only two hours and doing a mediocre job.  If I charged by the house, I would earn more money by doing only a mediocre job and doing more houses per day, but some of my customers might decide to fire me for not doing a very good job.

I think is really important to point out that doctors often lack knowledge when it comes to the medications they prescribe, while they have a good general idea of the pros and cons of taking a medication as well of the interactions, sometimes is best to ask your pharmacist for a better picture of what the medication does and how it can affect you.

Sometimes I don't think Dr.s know the answers or they assume we already know.  PCP are good at basic problems, but they usually aren't so good when you have a specialized condition.  My previous provider only gave each patient 15 minutes.  It always seemed like she was in a rush to get me out of there.  I later learned they would often double book patients.  This was good when I needed to be worked in with a UTI.  When I needed questions answered it wasn't so good.

I was on Synthroid for 10 years before I found out to take it 30 minutes before eating and drinking.  I was also never told not to take it with Calcium.  Pharmacy's have gotten much better about providing drug interaction sheets, but how many of us ever read them?  When I had my UTI I read the sheet because I was bored.  That was the only reason I found out that I couldn't take the antibiotic with calcium and iron. 

I think we have to be our best advocate.  I have learned I have to research everything myself. We also have to be willing to ask questions. 

I had multiple issues with my nutritonist misinforming me about calcium (my instructions specifically said get calcium citrate, which she crossed out and wrote calcium carbonate with a star next to it).  I of course found out here I needed the citrate.  Kelly, you stressed the ASMBS and their guide really helped me.  I am sure that she does not even know about it.  My doctor is great don't get me wrong, but when I went to their site I was disappointed to see he wasn't a member. 

I thought the nutritionist had also told me that I should take magnesium citrate the night before surgery, but couldn't remember for sure.  Called the doctor's office, got my doctor's partner and he said don't take it.  I did anyway and found out my doctor said I was right.

She said at first get a chewable multivitamin and take one a day.  Post op I called her and told her they really made me want to throw up.  She told me to go to Flinstones gummies.  After researching here of course I found that we are supposed to get 200% RDA on the vitamins.

To make a long story short, I had to replace most of my daily supplements post op that I had bought on her recommendation and the paperwork they handed out.

My wife is much tougher than me - she called up and demanded money back from the $500 program fee they charged due to all the misinformation - we really didn't receive what we paid for.

The nutritionist's supervisor called me back with apologies, stating that they were setting up a meeting with all the office and including the surgeons as well.  She was familiar with ASMBS and the requirements, so hopefully some good will come from the complaining, and they will revise their paperwork - I found some other diet guidelines online from bariatric centers that were much more comprehensive.

I got a little lucky too - my pharmacist had gastric bypass - so he was pretty helpful in the drugs and supplements area.  Found him post-op of course. :)

I learned alot from this experience - more questioning, more research - the internet is a wonderful thing.  I try to give my experience which started out rough with some complications to others going into surgery - I was given the "you're going to do great, be back to work in a week" and everyone I knew personally that had the surgery had no complications.  But the doctors office or RN in the nutritionist's office could have been a heck of alot more revealing as to the specifics of the complications - not that it would have changed my mind, I might not have been so suprised to get rushed to ICU!