The New England Journal of Medicine ran a series of articles on the relationship between patients and doctors.

One hopeful thought was that the choice of treatments for an individual patient should take into account what that patient prefers. The idea is that the doctor brings medical training and experience and patients bring their values and priorities to the table. Then they jointly choose the treatment that suits that patient best.

This approach is called "shared decision-making."

How can you argue with that?

It is curious, though, that even thoughtful, well-meaning doctors seem to subtly discredit the role of patients in shared decision-making.

For instance, consider the three concrete examples of shared decision-making that one doctor described. First, "the right of a competent adult to refuse a lifesaving blood transfusion"; second, "the right of a patient to refuse mechanical ventilation for a treatable and reversible cause of respiratory failure"; and third, in the opposite direction, "patients' rights to demand care that physicians regard as medically inappropriate (such as) situations in which the likelihood of successful resuscitation would be less than 1 percent."

That is, all the concrete examples are about patients making the "wrong" choice.

The author of the article mentions that more routine shared decisions are made "in clinics every day." But by not giving even a single example, he focuses attention on the cases that make patients look irrational and heedless.

The author noted that historically, "the relationship between patients and doctors" was "framed in terms of benevolent paternalism." If many doctors still believe that patients routinely make bad decisions, of course they see it as their job to decide for them.

And in fact, that's often what happens.

The Wall Street Journal reported on a study written up in the Journal of General Internal Medicine. The study was based in part on a survey of patients who had had surgery to implant stents - tiny little scaffolds used to prop open blood vessels.

According to one of the authors, other options for treatment are considered to be at least as good as using stents.

But only 10 percent of the patients given stents said that their doctors mentioned any other option before operating on them.

Only 19 percent said that their doctors mentioned any possible downsides from stenting. The Mayo Clinic reports that possible side effects include blood clots and kidney damage, among many others.

Only 16 percent of the patients remember being asked what treatment they preferred.

The Wall Street Journal article pointed out that for patients to make good decisions, at least three things need to be true. First, they are told what the reasonable treatment options are. Second, the pros and cons of each option are explained to them. Third, once they know their options, they are asked what they prefer.

These three elements were largely absent from the study.

Shared decision-making is a basic building block of "patient-centered" care. "Patient-centered" care, another article in the New England Journal of Medicine explains, "seeks to focus medical attention on the individual patient's needs and concerns, rather than the doctor's."

The doctor who wrote that article went on to reveal his aversion to giving up the central role.

He started out well enough, comparing a doctor-centered view of the world to the ancient belief that the earth was the center of the universe and that the sun and the other planets revolved around it. In his analogy, the doctor is the earth and patients are the sun and planets orbiting around it.

He contrasted that view with a patient-centered framework, in which all the planets, including earth, revolve around the sun. In this analogy, the patients are the sun.

Then he explained why, in his opinion, neither of these frameworks hits the mark.

"The flaw in the metaphor is that the patient and the doctor must coexist in a ... relation of mutual and highly interwoven prerogatives. Neither is the king, and neither is the sun. Health relies on collaboration between the patient and the doctor ... Patient and physician must therefore meet as equals, bringing different knowledge, needs, concerns, and gravitational pull but neither claiming a position of centrality."

He continued, "A better metaphor might be a pair of binary stars orbiting a common center of gravity."


It is wrenching for many doctors to consider giving up center stage. One has to give the doctor credit for trying to get at least halfway there, to acknowledge, albeit somewhat grudgingly, that doctors need to share the limelight with patients.

But the author went horribly wrong with his metaphor.

What does occupy "a position of centrality" in health care, if it is not a focus on meeting the patient's needs? What is the "common center of gravity" that should control both the doctor and the patient?

The author was entirely silent on this question. He did not propose that the doctor and patient be joined in the examining room by a third party presumed to carry more weight. For example, he did not suggest that they should yield to the concept of "public health." So let's set that possibility aside.

When building houses, most people hire general contractors. They know dramatically more about building than the homeowners do. Homeowners ignore the expert's advice at their peril. But that doesn't make the two parties equal players orbiting a third unnamed player that they both serve.

People don't revere experts who claim that their own priorities are equal in importance to those of the people they serve. People revere experts who do an outstanding job helping those who consult them to get results that meet their needs.