The shift in medical practice toward patient autonomy is a pivotal one and a beacon of enlightenment. It has transformed the traditional paternalistic model into a collaborative one. In this new approach, the doctor facilitates the patient’s achievement of mutually agreed-upon goals. This shift represents a significant advancement in patient rights, acknowledging their fundamental right to make decisions that directly affect them.
While the ideal patient-doctor relationship is widely accepted in principle, the current medical practice needs significant change. It’s crucial to recognize that many doctors, consciously or unconsciously, impose their preferences on their patients. This underscores the need for intentional training to prevent unintentional influence on patient decisions.
These considerations came to mind during my recent experience and how troubling I found the interaction. A pulmonologist was consulted on the case of a 77-year-old chronic smoker patient with lung nodules detected during a CT scan. My colleague’s immediate question and assumption was whether this pointed to a cancer diagnosis. He spent the next half hour explaining to the patient and his wife the procedures required to find a definitive answer to this question. His recommendations included a robotic bronchoscopy in which the patient would be under general anesthesia for two hours and would need to breathe high-concentration oxygen due to his diminished lung capacity. The procedure carried a risk of even death due to oxygen deprivation.
Despite the risk, my fellow treating physician felt this procedure was necessary. Professionally, this could be a reasonable recommendation given the possibility of a serious condition needing immediate treatment.
However, there was one crucial factor to consider in the risk/benefit ratio of the course of action. The patient had advanced COPD. He was already so weak that he could barely move and couldn’t go to the bathroom by himself. It was very possible that this patient would not survive a course of chemotherapy or radiation. His wife sat at his bedside, clutching her husband’s hand and asking us to do everything to save her husband’s life. But could she reconcile the fact that treating for cancer might, in itself, kill her husband? I felt I had to provide some perspective in this emotionally charged situation. I spoke up.
“You know,” I said cautiously, “as my colleague has mentioned, the robotic bronchoscopy procedure carries significant risks. A simple bronchoscopy with lavage would also be possible, with fewer risks. This could tell us if you have cancer, but it may fail to alleviate your symptoms.” The patient’s wife blinked as she heard my recommendation, but the patient seemed to look at me with calm gratitude.
It was not my decision, but the patient and his wife needed to be aware of all options, not just the one that was first on the list in the default doctor handbook.
Reflecting on this interaction, I realized my colleague had never asked the patient, “What outcome do you want? How extreme of treatment would you consider?” It often doesn’t occur to us that patients want to make limited efforts to extend their lifespan or avoid a given outcome, so as to prioritize quality of life. However, we are responsible for informing patients of their options, risks, and benefits. Ultimately, they must make the decision, and doctors must ensure that the decision is made with the most information available about the risks and benefits of every option. Patient feedback is crucial in this process, as it provides valuable insights into their preferences and helps us tailor our recommendations accordingly.
Even when doing so, our attitudes and choice of words can influence a patient’s decision. Research findings powerfully demonstrate this effect. For instance, a doctor’s confident tone when discussing a treatment option can make a patient more likely to choose that option, even if it may not be the best fit for their circumstances.
Survey research indicates that “interviewer effects” refer to changes that survey research staff unconsciously introduce into interviewees’ answers to survey questions. This was discovered through inconsistencies in the results of survey research.
Of course, such wild discrepancies demand further analysis. This underscores the need for continuous training and self-awareness among medical professionals to avoid unconscious influence on patient decisions and promote a culture of patient autonomy.
Studies have shown how interviewers can unconsciously change people’s answers. In some cases, the answers survey subjects give to interviewers depend on the interviewer’s training and attitude. Interviewer differences are significantly pronounced when respondents are answering complex or sensitive questions. Most decisions asked of patients in medical settings qualify as “difficult” or “sensitive questions.”
This underscores doctors’ significant influence on their patients and their decisions about their care. Just as the same interviewee can answer two interviewers differently, patients will likely make different decisions depending on their doctor’s attitude and approach. This is not just a theoretical concept; it is a reality in our daily practice and underscores the weight of our responsibility in patient care. Failure to respect patient autonomy can lead to decisions not in the patient’s best interest, potentially resulting in adverse health outcomes.
As doctors, we should be acutely aware of the power of our words. Our tone and words can significantly influence what complaints, questions, and concerns patients feel comfortable sharing. How we explain a procedure and the words we use to discuss treatment options can heavily influence how patients weigh their health objectives against the difficulties and risks of each option.
Understandably, there is no such thing as a perfectly unbiased doctor. But how mindful are we of our patients’ autonomy? Do we take time to lay out every treatment option, along with its risks and benefits, in a quantifiable and objective way, even for those options that are not primary in our estimation? Or do we make declarative statements to our patients about what we think is the best course of action and not even explain our recommendations?
A few days later, I called the patient to see how he was doing. He happily reported getting the bronchial lavage and electing to forgo the robotic bronchoscopy. His wife was struggling with her husband’s choice. But her husband knew the same thing I knew. Namely, that he might not live long enough for cancer to kill him anyway, and he wanted to live the rest of his days in peace, free from the risks of brain damage and the side effects of chemotherapy. Sadly, a week later, the patient passed away.
How can we, as health care professionals, actively ensure that our patient’s wishes and preferences are prioritized individually rather than applying a one-size-fits-all approach? What measures can we implement to break from routine practices and truly engage with our patients to understand their unique health goals and values?
As the medical field progresses in the coming decades, the emphasis on personalized care will become increasingly important. We can learn from extensive and ongoing survey research highlighting the biases and pitfalls that can occur when we share information or solicit patient feedback. Understanding these biases is the key to enhancing patient communication and fostering a more empathetic and tailored approach to patient care. Ultimately, this should lead to improved outcomes and patient satisfaction. These insights should then be translated into documented and transferable practices that can be broadly implemented into medical school curricula to prepare the next generation of medical practitioners.
How can physicians better support patient autonomy while minimizing unconscious bias in treatment recommendations? Share in the comments.
Dr. Francisco M. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes and general musculoskeletal disorders. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine. In his free time, he enjoys working out, playing the violin, and spending time with his five grandchildren. He is a 2024–2025 Doximity Op-Med Fellow.
Image by Maria Petrishina / Getty Images
