Prescriptions for Health Providers

Tovia G. Freedman, DSW, LCSW

Disclosures

Cancer Nurs. 2003;26(4) 

In This Article

Background

Currently, Halsted's radical mastectomy is rarely practiced and has been replaced by lumpectomy, which is less extensive than a total or partial mastectomy. Yet, Halsted's theoretical conceptualization of cancer as a systemic disease has been operational for well over a century.[2] The standard complete axillary dissection of the lymph nodes has been replaced in appropriate situations by sentinel node biopsy.[3,4] Chemotherapeutic agents have changed, primarily in dosage and administration sequences, and irradiation has been reduced to minimize long-term side effects. However, women still are faced with decisions and choices about how to approach breast cancer because the options have not changed enough to provide certainty of outcome.

The Parsonian idea that in the doctor-patient relationship 'reciprocity must be suspended'[5] was the dominant concept that dictated the status quo between physician and patient well into the 1960s. However, the roles of the patient and the physician have changed. Physicians have acquired better tools to palliate and heal; patients have greater access through the lay media [6,7] and the Internet to cancer information; cancer has become politicized[8]; and the role of women has changed.[9] The requirement for informed voluntary consent to treatment and participation in clinically oriented human research, enforced by government mandate, requires conversation between physician-researchers and patient-subjects.[10,11,12]

In addition, changes experienced during the 1980s and 1990s brought about a fundamental change in the delivery of medical service and care. The process of decision making in the medical encounter is multifaceted and 'a combination of medical, emotional, aesthetic, religious, philosophical, social, interpersonal, and personal judgments.'[11] (pp87-88) Moreover, decisions are not one-time discrete events, nor do they take place in a vacuum. The decision-making context includes explicit and implicit rules that govern the medical encounter, thereby influencing the ultimate decisions that are made and who makes them. These rules are based on societal values and norms that govern physician-patient relationships such as: the sociocultural context in which treatment is offered, the psychological and social state of the female patient, the medical factors related to the stage of disease.[13]

Quill and Brody have suggested a model of patient-physician interaction they term 'enhanced autonomy,'[14] (p763) a model of collaboration that would provide a balance between physician recommendation and patient autonomy. With this model, the patient would make choices based on the physician's experience and the medical facts. Silliman et al,[15] in their study of older women, say that age, marital status, and interaction with physicians play an important and even defining role in how older women make decisions regarding their therapy for breast cancer. They have suggested that women may be 'better served if they are offered choices from among definitive therapies.' [15] (p1326)

Surbone[16] stated that 'obligations in the patient-doctor relationship are mutual [as] exemplified by the case of truth telling.' Surbone's inquiries suggest that 'it is advantageous to the patient and to the physician to tell the truth, and [that] reciprocity certainly must exist with respect to truth-telling (the physician not only has a duty to be truthful, but he or she also expects the patient's narrative to be truthful to what the patient experiences, for correct diagnosis, prognosis, and treatment to be possible).' [16] (pp60-61) In addition, shared decision making has been linked to positive patient outcomes, and research has demonstrated that when the patient participates in treatment decisions her quality of life is better.[17]

The context of the medical encounter goes far beyond biology to encompass personal, social, cultural, and environmental components. [18,19,20] The medical encounter engenders relationships that are inherently imbalanced in terms of authority, and therefore power,[21] because the physician 'owns' the territory, whereas the patient is a temporary visitor, and one of many. Each patient has an idiosyncratic response to medical information and to the actual treatment. Patients are offered 'the standard of care,' accepted as such for that moment in time, using guidelines that focus on a general population of patients. As numerous physicians in this study stated: 'We treat 80% of patients with chemotherapy after surgery so that the 20% who need the treatment will get it.'

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