What do we mean by partnership in making decisions about treatment?
What do we mean by partnership in making decisions about treatment?
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DOI：
10.1136/bmj.319.7212.780
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发表时间：
1999-09-18
影响因子：
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通讯作者：
Gafni, A
中科院分区：
文献类型：
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作者：
Charles, C;Whelan, T;Gafni, A
几十年来，在医疗问题上做出治疗决定的主要方法一直是家长式的。近年来，这种模式受到了医生、病人、医学伦理学家和研究人员的挑战，他们主张医生和病人之间建立更多的伙伴关系。28 - 13造成这一挑战的原因已在其他地方详细描述，包括消费主义的兴起和保健决策中消费者主权的概念；强调挑战医学权威的妇女运动；通过了注重病人保健权利的立法；医生执业模式的小范围差异似乎与健康状况的差异无关。虽然前三个因素被看作是患者参与医疗保健决策的贡献者或推手，但第四个因素突出了医疗保健的不精确性或“艺术”：具有类似临床问题的患者可能会从不同的医生那里接受不同的治疗，部分原因是不同地区的实践模式存在系统差异。14,15 .呼吁医患合作，为解决决定治疗的任务提供了超越家长式作风的选择。但这也带来了新的复杂性。因为病人和医生之间的伙伴关系可以采取不同的形式，所以这种模式看起来并不直观。《牛津英语词典》（1995）将合伙人定义为“与他人分享或参与的人”。这个定义没有回答几个重要的问题。例如，伙伴关系的概念是否意味着医生和病人都需要分享决策过程的所有部分？双方分享的是什么，分享到什么程度？谁负责确定伙伴关系是否可行，并负责启动第一步？在保持伙伴关系概念的同时，病人和医生的角色是否有变化的空间？在什么样的临床环境下，医患合作关系是最需要的？根据我们之前的概念性论文，本文确定并描述了在做出治疗决策的背景下，医生和患者之间可以建立的不同类型的伙伴关系。
For many decades, the dominant approach to making decisions about treatment in the medical encounter has been one of paternalism. 1–7 In recent years this model has been challenged by doctors, patients, medical ethicists, and researchers who advocate more of a partnership relation between doctors and patients. 2 8–13 The reasons for this challenge have been described in detail elsewhere and include the rise of consumerism and the notion of consumer sovereignty in healthcare decision making; the women’s movement with its emphasis on challenging medical authority; the passage of legislation focusing on patients’ rights in health care; and small area variations in doctors’ practice patterns that seem unrelated to differences in health status. 7 Though the first three factors are seen as either contributors to or facilitators of patients’ participation in making decisions about health care, the fourth highlights the imprecision or the “art” of medical care14: patients with similar clinical problems may receive different treatments from different doctors, due in part to systematic variations in practice patterns across geographical areas. 14 15 The call for doctor-patient partnerships opens up options beyond paternalism for approaching the task of making decisions about treatment. But it also raises new complexities. Because a partnership between patient and doctor can take different forms, it is not intuitively apparent what this model would look like. The Oxford English Dictionary (1995) defines a partner as “a person who shares or takes part with another or others.” This definition leaves several important questions unanswered. For example, does the concept of a partnership imply that both doctor and patient need to share all parts of the decision making process? What is it that both parties are sharing, and to what degree? Who is responsible for determining if a partnership is possible and for initiating the first steps?Is there room for variation in patients’ and doctors’ roles while still retaining the concept of a partnership? What are the clinical contexts within which a doctor-patient partnership is most needed? Drawing on our earlier conceptual papers, 6 7 this article identifies and describes different types of partnerships that can be developed between a doctor and patient in the context of making decisions about treatment.