Breakdowns in physician communication 
can undermine patient autonomy

Peter A. Ubel, MD
Peter A. Ubel, MD

As a physician and behavioral scientist, Peter A. Ubel, MD, has long been interested in exploring the “quirks in human nature” that influence people’s lives. Those quirks, he said, include a mixture of rational and irrational forces that can profoundly affect a person’s health and happiness.

Of particular interest to Dr. Ubel, and the subject of his current research, are the roles that a patient’s values and preferences play in the health care decision-making process. Dr. Ubel will discuss the importance of patient autonomy and the challenges of shared decision making Wednesday morning during the annual John J. Conley Ethics and Philosophy Lecture, Empowerment Failure: How Physician Communication Breakdowns Undermine Patient Autonomy. Dr. Ubel is professor of medicine, Duke University School of Medicine, and the Madge and Dennis T. McLawhorn University Professor and associate faculty director of health sector management, Duke’s Fuqua School of Business Administration and Sanford School of Public Policy, Durham, NC.

“In medical care, there are times when the best treatment alternative for a specific patient depends on that patient’s goals or preferences. There’s not always one, clear-cut right or wrong medical option,” he said. “In those situations, physicians need to be able to partner with their patients to help them find the choice that promotes their goals and values, and promotes their autonomy.”

In his studies involving prostate cancer patients, Dr. Ubel found that treatment decisions were often based solely on a physician’s recommendation, with little or no attempt to determine the patient’s goals or preferences.

“When treating a patient with prostate cancer, a physician might recommend surveillance of the cancer, but some patients might worry or have anxiety with an untreated cancer in their body and the anticipation that, in six months, they’ll get tested and get some bad news,” Dr. Ubel said. “On the other hand, the physician might suggest surgery or radiation to get rid of the cancer but, again, some patients might have severe anxiety about experiencing erectile dysfunction, bladder dysfunction, or other potential side effects.”

When discussing treatment options with patients, Dr. Ubel said some physicians simply don’t know how to effectively elicit the patient’s goals and concerns or know how to process them in a way that informs their treatment recommendations.

“Most of the physicians in our study really tried to promote patient autonomy,” Dr. Ubel said. “They told patients that it was their decision to make and told them all the treatment options. But then they didn’t know how to elicit patient preferences and then show the patient what that meant in terms of what treatment was best for them.”

Dr. Ubel said that teaching physicians the importance of shared decision making and patient autonomy is not enough—they must also learn how to promote it.

“We need to recognize that there are circumstances when reasonable patients could disagree about which treatments are best for them,” Dr. Ubel said. “In those situations, you need to try to find out what the patient cares about and then, if you’re going to make a treatment recommendation, make sure the patient understands how it relates to his or her goals so the patient can see that you understand him or her and are making a good recommendation.”

The John J. Conley Ethics and Philosophy Lecture is sponsored by the Committee on Ethics and has been generously supported since 1991 by John J. Conley, MD, FACS, New York, NY, to explore ethical issues in surgery. Dr. Conley died in 1999, but his legacy continues and his memory is honored at this annual lecture.