Do You Want Your Doctor to Tell You What to Do?

There's been a lot written in the past few years about the evolution of the traditional paternalistic doctor-knows-best approach to a "patient centered" model of care in which patient and doctor are collaborators, sharing information and discussing treatment options as equal partners. It sounds nicely egalitarian, and presumably patients who are more involved in their care manage their health better than those unenlightened souls who actually want their doctor to tell them what to do. But hold on. A study in this week's Annals of Behavioral Medicine suggests it might be less effective, at least for some people.

All 189 participants, mostly older midwestern men, had high blood pressure and were taking medications to bring it down as well as other drugs to lower their LDL cholesterol, since hypertension is a risk factor for heart disease. More than half also had diabetes and were monitoring their blood sugar. They filled out a nine-item portion of a self-assessment survey called the Patient-Practitioner Orientation Scale, rating themselves from 1 to 6 on how strongly they agreed or disagreed with statements that reflected either a traditional relationship, such as "The doctor is the one who should decide what gets talked about during a visit," or a more patient-centered one, such as "Patients should be treated as if they were partners with the doctor, equal in power and status." And they were asked whether they had received information about their medications from the Internet, a friend, a pharmacist, and other specific sources.

It's not surprising that the higher patients scored in their preference for patient-centered care, the more likely it was that they had gotten information from the Internet or someone besides their doctor. But there was also a reverse correlation between the PPOS score and how well a patient's blood pressure and cholesterol were controlled. The stronger the desire for a respectful, collaborative partnership, the higher the blood pressure and cholesterol. (Blood sugar wasn't related in either direction.)

Why? Who knows? The study authors speculate that perhaps the kind of patient who chafes at being told what to do is more likely to disobey. Or there may have been a clash between the way the patients wanted to be perceived and the way their doctors saw them. That kind of mismatch can affect quality of care.

It's a small study, hardly definitive, but I hope there can be a larger follow-up. Perhaps one reason many patients mismanage their health is that, consciously or not, they are reacting to their provider's style of doctoring. I don't think it's too much to ask physicians to keep that in mind. The best medicine has to offer isn't worth much if patients reject it.