January 31, 2012

The Horse by the Door


Horse Portrait

There is a plaque in Cambridge, England, located beneath a painting of Thomas Hobson, a livery stable owner.  Hobson advertised that he had a large stable of horses, indeed at one point as many as 40 from which a customer could choose.  This created the impression to the customer that there was a clear choice of mount. However, despite this appearance, Hobson required that the customer choose only the horse in the stall that was closest to the door.  Truly, despite the illusion of choice, there was no real choice at all.

We face a similar potential balance in current medical practice.  Indeed, over the last twenty years, we have seen the development of two broad movements in medical care.

The first, guideline-based treatment, reflects strict adherence to national standards for medical care, with pay for performance.  The second focuses on patient engagement, shared decision-making and transparency.  Usually, the decisions that are reached by the two approaches are similar, particularly in acute medical care.  However, all of us have seen a growing desire on the part of our patients and their families to share in decision-making with their provider.

The problem arises when the recommendations are different.  For example, a young patient with mild to moderate high blood pressure may choose six more months of diet and exercise before beginning high blood pressure medication, while the national guidelines that the provider may be judged upon would require beginning medication now.  This can result in the patient being labeled as “non-compliant,” and the provider being labeled as “difficult.” Fundamentally, this reflects the misassumption on the part of the provider that the guidelines are rules, as opposed to recommendations.

Fundamentally, we need to strive for delivering health care that can acknowledge different perspectives that can include an individual patient’s values.  We need to develop the capacity to listen to a patient’s story, and consciously integrate what they value into our final recommendation.  Truly, we will be judged as much by how well we listen, as by what we say.

We truly cannot force them to take the horse by the door, no matter who insists we do so.

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