Patient-provider interactions and “Therapeutic Privilege”

You’re probably wondering what “therapeutic privilege” means, since it’s written right here at the top of the page. It refers to the physician-deemed withholding of medical information from patients when sharing this information might cause more harm than good. Or more simply, doctors don’t have to tell you squat. Whether you empower your doctors to behave this way, or if you find it arrogant and presumptuous, we practice this all the time. Most of the time, we don’t even realize it. When you get routine blood work for kidney function monitoring, and I don’t tell you that–incidentally–your serum glucose is 143 mg/dL (normal for adults is about 126 or less), I’m not intentionally withholding data that may suggest you could develop diabetes and eventually strokes or heart attacks. I’m probably assuming you had a granola bar or soda before the blood work was collected, and this elevated your serum glucose level. I don’t think this sort of behavior makes physicians neglectful, or bad people. We simply have to interpret a host of data and present the most clinically meaningful information to the patient so he or she can appropriately react to it. If we fail to recognize the needs and interests of the patient, and falsely assume how he or she might react to new information, then we aren’t doing our jobs right.

And doing our jobs right is the focus of our BrainWaves podcast this week.

This week’s episode features Patrick Green, a long-time friend of mine, and an oncology patient. In an unfortunate yet serendipitous sequence of events, he was diagnosed with papillary thyroid carcinoma. Through a work-related health screening, which utilized ultrasound imaging, he was found to have an abnormality of his thyroid, so he was encouraged to see his primary care physician. Several appointments later, he had a tissue diagnosis of thyroid cancer. While this is not a neurologic disease, we featured his case on BrainWaves because he has shared some insightful knowledge about the patient’s perspective with me. An engineer, with a healthy scientific background, Patrick realizes the value placed on discrete data points and expert [clinician] opinion when making medical decisions. But he also discusses the role patients can, and should, play in directing their medical care. Patients may not always be the authors of their health, but they are authors of their healthcare.

Clinic counseling session. Adapted from https://www.flickr.com/photos/59308652@N02/5431718990/ under a Creative Commons license.

The ways in which patient preferences and electronic information sharing are incorporated into medical planning formed the basis for this interview, so I hope you (as patients or providers out there) can learn from the experience of others. For more information on how doctors [should] make decisions about withholding information from patients, I will refer you to this perspective piece published in the New England Journal of Medicine in 2010 by Epstein and colleagues. For those of you not interested in reading more on the subject, because I’ve bored you enough here, just spend more time talking with your patients. 90% of the time they might just tell you what they want to hear.

 

[Jim Siegler]


REFERENCES

Epstein RM, Korones DN and Quill TE. Withholding information from patients–when less is more. The New England journal of medicine. 2010;362:380-1.

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