Kent Bottles: Is Good Patient Care About Choice or Collaboration?

My July 23, 2009 blog on the ideal relationship between patients and doctors elicited more comments than most of my postings.  ePatient Dave was interested enough to repost that blog on his site, which elicited even more comments. One comment from Anne Marie Cunningham suggested that I read The Logic of Care:  Health and the Problem of Patient Choice by Annemarie Mol, the Socrates Professor of Political Philosophy at the University of Twente, the Netherlands.

Even though this slender paperback cost more than $40 on Amazon, I’m glad I bought and read it.  Mol has thought long and hard about how framing the doctor/patient relationship around the question of choice and who has more power misses much of what is important and meaningful in the interaction between professional and patient.

By studying what really happens to patients, nurses, doctors, and others in a diabetes clinic in Holland, Mol concludes that it is more useful to think of the doctor/patient relationship as a “logic of care” rather than a “logic of choice.” This book has profoundly changed the way I think about this central theme in health care reform.  Mol’s logic is a way to understand the “rationale of the practices I am studying.” “I will make words for, and out of, practices.  And I will do so comparatively, using contrast as a way of gaining insight.  This book articulates the logic of care through a detailed comparison with the logic of choice.”

The logic of choice summarized in my July 23 blog is well known: supply should follow demand, and care should be guided by what patients want.  Many advocate that the term “patient” is too passive and should be replaced by “customer,” a term that emphasizes action and empowerment.  Mol objects to this on the grounds that what she observes in the consulting room between physician and diabetes patient is not a commercial transaction defined with a beginning and an end.  Instead, Mol sees an interaction that is open-ended, non-linear, and involved with many different actors.  Mol also notes that the market model of choice involves target groups and selling; if the target group is too small then the company ignores that segment of the market.  In the examining room, the physician and nurse do not give up on anyone.

“The art of care is to figure out how various actors (professionals, medication, machines, the person with a disease and others concerned) might best collaborate in order to improve, or stabilize, a person’s situation.  What to do and how to share the doing? In the logic of care, patients are not a target group, but crucial members of the care team.”

Mol also explores the “gap between well-ordered theories that tell them how to handle science and technology and the far messier practices in their consulting rooms.”  Within the logic of choice, scientific knowledge is a growing collection of acts that gradually increase in certainty.  Physicians should provide their patients with accurate information so the patient can determine the value of possible courses of action (tight or mild regulation of blood sugars, a pen or a pump, etc.).

While the logic of choice separates facts from values, Mol’s logic of care attends to them jointly as the doctor, nurse, patient, family, and others try to achieve a balance between what evidence-based medicine dictates and what is possible for this individual patient.  For example, Mol describes a patient who must choose between tight control and being able to drive his car without fear of hypoglycemia because he has to drive to keep his job.  “Good professionals need to ask patients about their experiences and attend carefully to what they are told, even if there is nothing about it in the clinical trial literature.”  According to Mol, “the crucial question in relation to doctoring is not who is in charge, but whether or not the various activities involved are well attuned to one another.”

When Mol examines the question of patient guilt, she believes the logic of care better serves sick patients than the logic of choice.  “In the logic of choice, having a choice implies that one is responsible for what follows.”  “Does your insulin pump not live up to its promises? Bad luck. You wanted it.”  In the logic of care, when things go wrong you do not have to blame yourself or feel guilty.  “The logic of care does not impose guilt, but calls for tenacity.  For a sticky combination of adaptability and perseverance.”  Mol also describes the criticisms of the logic of choice centering on some patients with coma, depression, and/or high fever not being able to make good decisions and the research that establishes that all Homo sapiens have some trouble with making sound decisions.

The value of this book for me is that it made me think deeper about my reservations about the patient as customer always being right in their demands of providers.  Mol argues that good care is not all about making thought out individual care choices; rather she believes good care grows out of collaboration and ongoing attempts to balance knowledge and technologies with diseased bodies and complex lives.

The final word goes to Dr.Victor Montori, a shared decision-making expert at the Mayo Clinic in Rochester, Minnesota.  In a comment to the July blog about the doctor/patient relationship, Victor wrote, “Care, empathy, guidance, choice, expertise, evidence, context, values and preferences – all matter.  What is the right combination?  Ahhh…the right combination is the one that furthers the goals of the patient.”