Decision Making

“Doctor, What Would You Do?”

“Doctor, what would you do?”….DWWYD…or more precisely:
“What would you do if this was your child?”
Fifteen years ago I rarely heard this question from parents
and caregivers.  Now this is a commonly asked
question.  The media (e.g. Parents
Magazine) and advocacy groups have advocated this question as a good one to ask
medical providers, when they are faced with having to make a decision about a diagnostic
test or treatment.  Its quoted purpose is
to simplify the issues, factors, cofounding variables of a medical problem or
issue, which would then make it easier for non-medical people to
understand.  The common thought is “well,
if you would do “it” for your child then it must be the correct action for me
to take for my child.  However, this is
not that simple.
What is the right decision for my child, and everyone else’s
children, is dependent on multiple issues: personal and family values,
religion, culture, heritage, socioeconomic status, and many other personal
perspectives.  So what is the right path
for my child may be different than the one you may choose for your child.
This is a nice article from AAP about this topic:
My practice is focused on spine problems in children and
adolescents.  I see the full spectrum of
problem severity.  On one end some are very
mild and need no treatment, and at the other end there are severe problems
which need major spinal reconstructions.
So, from the parents/caregivers perspective the decision process may be
an easy one or may be very complicated, convoluted and have significant potential
risks to their child. 
So how do I, as the physician, present treatment decisions
to parents and caregivers? 
First of all, I educate.
In order to make a good decision it is important to objectively educate parents/caregivers
with the best, highest-level of scientific evidence and medical knowledge
currently available about their child’s problem.  I always focus on what would I want to know
if I was in their position, as if it were my child who needed a care decision.   
Secondly, it is important to detail how their child fits in
the framework of medical knowledge.  By
doing this it helps create a platform on which parents can better understand
the issues treatment alternatives, benefits, complications and risks.  It empowers the parents, engaging them to be
an active participant in their child’s medical care. 
Thirdly, my goal when presenting treatments, is
to only present those which are reasonable and based on scientific
information.  I never offer a treatment
options if it will not provide similar or relatively equivalent long-term
outcomes, with similar complication types and frequencies. A treatment option
may be reasonable alternative even it requires more surgeries (actual or
potential), more trips to the hospital or clinic, more radiographs, a longer
postoperative recovery, with more activity restrictions and more pain
temporarily.  Those are short-term and
not long-term issues, though they may not be desirable.
Fourthly, I present the potential benefits and risks of the
treatment and their likelihood of occurring.
Personally I don’t like to present actual numbers like 99%, 75%, 20% or
1%.  Rather I like to focus more on low,
medium, high chances of an outcome or complication.  The reason I shy away from number is that it
can be hard to understand a 75% chance of some problem happening, since this
number is bases on population statistics.
A 75% chance means out of 100 people, 75 will have it happen to them,
and 25 will not have it happen to them.
However, each person will (100%) or will not (0%) have it happen to
them.  A person will not get 75% of the
outcome, they either will or will not get it.
Lastly, I give the parents/caregivers plenty of time to ask
questions, both in the office setting and after they go home with phone
conversations as needed.  The nice aspect
of pediatric spinal deformity problems, unlike severe medical problems, such as
cancer, is that there need to make a rapid decision is infrequent.  There is usually time to think, discuss, and
ask questions….and even get a second or third opinion from another physician.  I am never offended or disappointed if
parents/caregivers want another opinion.
It is their right to do so for their child and I fully support it.

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