Since When Do Doctors Ask for Permission?

Recently I came across an entry in the “Well” blog of the New York Times titled “Can We Talk About Your Weight?” In it, Barron H. Lerner, M.D.—a professor of medicine and population health at New York University Langone Medical Center and author of numerous books and essays—expresses incredulity upon hearing a fellow physician suggest during a medical talk that, before discussing the relationship between an unhealthy diet and a variety of medical ills, it’s a good idea for the doctor to ask the patient’s permission to raise the topic. Permission? Dr. Lerner asks himself—Since when do doctors with proven strategies for improving health ask for permission?

Although he clearly intends his questions to be rhetorical, we can offer Dr. Lerner a short and simple answer: Since motivational interviewing (MI) began to make its way into medical training and practice a couple of decades ago.

The source of Dr. Lerner’s incredulity is his way of thinking about the doctor-patient relationship. He accepts that patients should be, in his words, “the ultimate decision-makers” about which treatments they receive, and that physicians must obtain “informed consent” before embarking on a treatment course. But, he writes,

… when it comes to informing patients about potentially healthy interventions, I am not shy…

Call me a traditionalist or a closet paternalist, but I view each patient encounter as an opportunity to improve both physical and mental health.

Shouldn’t doctors have free rein not only to raise whatever topic they wish, but also to suggest it needs “fixing”?

Once again, a question that Dr. Lerner intends as rhetorical can be answered accurately in a way that he would not expect—in this case, by pointing out that he’s asking the wrong question. The issue is not (as he frames it earlier in his blog) whether or not doctors have the right to discuss diet and weight loss (or, for that matter, smoking, alcohol use, or any other lifestyle topic) with their patients. Rather, it’s what kind of effect might it have when doctors raise a topic and offer advice to change without knowing how the patient feels about discussing it at all?

And this question we can answer confidently, based upon a large body of research not only on the effectiveness of MI as a way of promoting health behavior change, but also on more general principles of effective communication. When people feel pressured to make choices other than the ones they prefer, they are apt to push back against that pressure and may react with anger. Research on the phenomenon of psychological reactance, which explains this tendency as based on a core human need to protect our freedom against perceived threats, has demonstrated in hundreds of studies how such pressure to change tends to backfire. Just think about the last time someone tried to “fix” something about you that you weren’t sure “needed fixing” or didn’t feel ready to address: how welcome was their advice?

Similarly, when people are presented with information that threatens their view of themselves as good, intelligent, and sensible—like, for example, the message that the way they like to eat is terrible for their health, or that their smoking is likely to kill them—they often feel defensive and reject the information. Unless, that is, they're helped to feel good about themselves at the same time. Research on self-affirmation theory shows that people given feedback about the health effects of their smoking are unlikely to try to quit unless they are also invited to think about ways in which they have successfully lived out their own values. Critical feedback that we weren’t expecting—or, worse, that we were dreading—can be distressing and even demoralizing; it’s much easier to accept and act upon when we’re confident that it’s not a comment on our worth as a person.

So how do these principles show up in a typical medical consultation? Here’s the (MI-consistent) approach that prompted Dr. Lerner’s objections:

I’d like to share with you how your food choices can help lower your cholesterol, blood pressure and blood sugar so that you may be able to avoid taking more medicine and be healthier. Would you like to hear about this?

And now ask yourself this: would you rather your doctor spoke to you this way—or in a way that implies that your doctor, and not you, decides what topics will be discussed and what information and advice you will hear?

People vary in how sensitive they are to the way their doctors communicate with them. But raising the topic of diet and weight without first establishing a safe and trusting relationship, asking permission, and emphasizing patient choice risks triggering reactance and defensiveness. Indeed, the comments in response to Dr. Lerner’s blog entry gives clear evidence of just this: every one of the “most recommended” comments takes him to task for perceived arrogance, insensitivity, or poor communication skills.

The irony of Dr. Lerner’s position—which, we should note, remains widespread among physicians—is that he is an outspoken and published advocate for doctors to change their practice on the basis of new evidence. In his 2014 essay for The Atlantic magazine, “When Doctors Act on Tradition and Emotion Over New Science,” he chides his fellow physicians for allowing their “emotional reluctance to change habits that [they] have relied upon for decades” to keep them from adopting new practices that have been shown to save patients’ lives. Acknowledging that “it is hard to practice medicine one way for so many years and then change,” he nonetheless argues against allowing “emotional and psychological reasons of dubious validity” to guide treatment recommendations and declares

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For my part, even though it will be a psychological challenge, I will try to adapt my practices to the changing landscape.

In his “Well” blog entry, Dr. Lerner shows that he has not yet recognized that physicians should be guided not only by evidence about WHAT to say to patients (i.e., the treatment recommendations they make) but also about HOW to say it. Here’s hoping, for the sake of their patients and the medical students they teach, that when it comes to their style of communication, Dr. Lerner and his colleagues will soon (to quote his own words in The Atlantic) “avoid reflexive thinking and carefully incorporate new insights.”