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Hot and Cold

There are cold decision making tools and there are hot decision making tools. Cold decisions are calculated and weighed against options. I call them cold because they are slow deliberate decisions not made solely on the basis of emotions. They are made primarily on facts, cold hard facts.

Hot decisions are made in the heat of the moment. Impulsive, quick, and many times made in a time of vulnerability, they can have lifetime consequences.

Most medical decisions are hot for patients but cold for clinicians. Patients, on the whole, only have to decide how to treat cancer one or at most two times in their lifetime. Clinician make such decisions every day. Patients don’t have time to explore options, weigh values or cost. Clinicians, at least in theory, do have evidence, studies and experience to guide them.

Yet a patient has to live with the reality of the decision. Clinicians go home at night.

This is illustrated in a typical cancer decision. A patient has a part of their body biopsied and is told to go home and wait to see if the pathologist says it is cancerous. At the most, they are given only vague information about what would happen if the biopsy was cancer.   When the test comes back it comes to the clinician who will read the document alone and be able to think how to present the results to the patient. Clinicians will present their preferred treatment option and the reason for this option but will give little thought to other options. If the patient questions the option presented the clinician does not welcome these questions, rather is irritated that their judgment is being questioned. The clinician, many times unknowingly, presents the options as a take it or leave it proposition. In fact, the only decision they want from the patient is do they want to do surgery today or early tomorrow.

Cold decision for the clinician, hot for the patient.

Many times this works out fine—the biopsy is normal or the surgery is all that is required. Other times it starts a cascade of increasingly complex and invasive medical procedures. But I think the real opportunity lost is education.

Patients, if they are going to be in charge of their healthcare, need to have time. Time to process, research, think and grieve. And, except in the cases of emergencies, there is time. Maybe there is not months but there is hours or a few minutes.   In other words, while the decision for patients may be warm it is not scalding.

As a clinician, try as I might to give more time, I can find myself being sucked into the demands to see more patients in less time. It helps if I remind myself, this is the first time the patient has questioned a fever or pain level and I need to be tolerant.

When I do this, I give my best explanations when the patient asks.

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