NEW APPROACHES TO THE ENCOUNTER
As technology and treatment options in sports medicine blossom, the nature of the patient-physician encounter also must change. In an article on decision making in orthopedics, Bryant and associates1 divided the patient-physician encounter into 3 categories of interactions: paternalism, informed decision making, and shared decision making.
Historically, paternalism dominated the landscape in a model sometimes known as “disease-centered care.” 2 In this model, the physician is an expert in injury and disease, has knowledge of the treatment options, controls the care, and dispenses information to the patient in discrete visits as he or she sees fit. As such, the physician assumes an autonomous role in selecting treatment.3,4
In the practice of sports medicine, the team physician typically adopts the paternalistic role. Decisions (eg, return to play) often are left to the medical staff, without an intimate assessment of patient values. If individual values are not factored into decision making, there is potential for harming the patient. For example, returning an athlete to play before an injury is completely rehabilitated because of pressure from the coaching staff could result in significant harm or reinjury.
Informed decision making
Later, the medical community began to recognize the importance of including the patient in the decision-making process and reversed the roles of patient and physician. In this informed decision-making model, in which the patient assumes ultimate responsibility for care, the physician presents information about the risks and benefits of various treatment methods. From this point on, the patient is left with complete autonomy on treatment options without more physician input.5,6
Although this model is rare in recreational sports, it may be more common in professional sports. The case of the finger-tip amputation of San Francisco 49ers defensive back Ronnie Lott’s pinkie during the 1985 NFL season to allow him to continue to play is a graphic example of the patient probably having autonomy in the ultimate choice of treatment. In this paradigm, the mantra of team first often heavily influences decision making capacity, possibly to the detriment of the patient.
Shared decision making
With all dramatic shifts in medicine, the pendulum tends to swing back to a middle stance. In this case, the middle is shared decision making, an amalgam of paternalism and informed decision making.
In shared decision making, the patient provides intimate information about his values and goals to the physician who, in turn, provides clinical expertise on the disease or injury state (including discussion about the current scientific literature on the topic, such as experiments, analysis, and forecasting). The final treatment course represents the best option in the context of the patient’s situation being melded with the physician’s knowledge of outcomes.7,8 As indicated by its name, shared decision making involves mutual responsibility; here there is the least possibility of harming the patient.
The nature of shared decision making is illustrated in a work by Eddy9: “the people whose preferences count are the patients, because they are the ones who will have to live (or die) with the outcomes. . . . Ideally you and I are not even in the picture. What matters is what Mrs Smith thinks. . . . It is also quite possible that Mrs Smith’s preferences will differ from Mrs Brown’s preferences. If so, both are correct, because ‘correct’ is defined separately for each woman. Assuming that both women are accurately informed regarding the outcomes, neither should be persuaded to change her mind.” There is 1 common injury, but sharing decisions with 2 patients who have 2 sets of values can result in different treatments. As long as the patients are adequately informed, both are correct and neither suffers from the decision.