By Edward Pullen, MD. Check out drpullen.com, a medical blog for the informed patient.

I believe that one of the most important things I can offer to my patients is help in keeping perspective when making medical decisions.  I have a fund of knowledge and experience that adds a layer of perspective to the patient’s own beliefs, situation and overall health scenario.  Hopefully, I can get enough of a feel for the patient’s own personal, psychological and interpersonal situation to add my own perspective to theirs to help advocate for them in keeping perspective on the issues they are facing.

By a physician’s balanced perspective, I mean the ability to look at the whole clinical, personal and psychological situation in which a medical decision is being made, and help their patient make choices that are aligned with both the medical facts and reality, as well as the their patient’s own beliefs, values and desires. Often, the emotional issues or prior anecdotal experiences of a patient can prevent them from keeping perspective in making important decisions. My role at times is to help them see the broader picture and make the best decisions.

Sometimes this is simple, but sometimes it’s not simple at all.  Let’s look at one simple and one complex example, and then summarize by looking at examples of times when keeping perspective helps with making the best choices.

Simple: A 45 year-old male with a blood pressure of 195/125 who has no symptoms but is a smoker, has a poor lipid profile and whose dad had coronary bypass surgery at age 50, is reluctant to take blood pressure medication because he “just hates to take pills.”  The physician has a simple task.  Find out the real reasons for being reluctant to take medication, present the facts (this fellow has greater than a 30% chance of a coronary event in the next 10 years), and find a way to convince him to use medications to control his blood pressure. In this case, the evidence that treatment of this patient’s hypertension along with his cholesterol can reduce his risk of an event to 11% (if systolic BP goal of <130 and total cholesterol goal of <180 are met). And if he can quit smoking as well, his risk will decrease to about 3%.  Presenting this evidence to the patient, along with finding out the reasons for disliking taking medications, is likely to persuade him to comply with therapy, and be hugely beneficial.

Complicated: A 39 year-old mother of two, who is divorced but involved in a new relationship with a childless man, is found to have an enlarged uterus on routine annual exam.  Ultrasound shows a thickened endometrial lining at 1.7 cm, and endometrial biopsy shows endometrial hyperplasia with atypia.  Her family physician refers her to a gynecologist for further evaluation, and she is presented with several options.  (1) She can have a laparoscopic-assisted vaginal hysterectomy to remove the uterus and assure no progression to endometrial cancer. (2) She can have a dialation and curettage (D&C), which will further assess the endometrial pathology and likely, but not absolutely, get rid of the atypical cells.  (3) She can take hormonal medications that cause  a “medical D&C” by bringing on  heavy menses, and try to rid her uterus of the hyperplastic lining.  Keeping perspective of her wishes, future plans and feelings about the options is very important in helping this woman make the best decision for her individual situation.

The former situation with the family doctor trying to convince the patient to treat their hypertension is straightforward.  Hopefully, the physician can help the patient in keeping perspective of the whole picture and will lead the patient to comply and take the drugs to reduce their risk of serious long and short-term cardiovascular problems.  In the latter case, the physician will hopefully discuss the needs of the woman involved and help her in keeping perspective of both the medical facts and risks as well as her feelings and needs in making her choice.  Does she want further children? How does she feel about a hysterectomy?  Is she willing to submit to long-term careful follow-up of the condition if she chooses a less aggressive therapy? Keeping perspective involves figuring out the needs of the patient involved.

Examples of when keeping perspective in mind rises to the top of the physician roles include:

• prostate cancer treatment, especially in the older man
• treatment of moderately-elevated LDL cholesterol
• whether to take estrogen for moderately-severe hot flashes and night sweats around the time of menopause
• whether to use oral contraceptives, an IUD, or barrier contraception at various times of your life
• whether to take Accutane for moderately-severe acne
• whether to start insulin for poorly controlled type 2 diabetes

The list could take up pages, as it really comes up to some degree with every physician visit.  Sometimes the issues are so simple as to be obvious to both the patient and the physician, and go almost without overt comment.  Other times, as the physician, we can help by labeling our role as helping the patient at keeping perspective, and assisting in their decision-making by adding our perspective while trying to understand theirs.