There is nothing special in this daily list of domestic decisions so I guess everyone lives each day making one decision after another. It seems however that decision-making in the physician’s office is a much more complicated matter that is very often quite stressful for the patient and at times difficult for the doctor. There are two reasons why making decisions regarding how to best treat an early prostate cancer or a small breast lump are more difficult than choosing a salad dressing for supper or a countertop during kitchen renovation. The first reason is that the man’s prostate cancer and the woman’s breast lump are simply more serious issues. Gravity of issue makes things more stressful. That’s life. The second reason decision-making in the medical arena is more complicated is that is not perfectly clear who is doing the deciding. Is it the patient or is it the physician that decides if the prostate cancer should be operated upon, treated by radiation, or cautiously observed to await any significant progression or health threat? Is the woman to decide if she should have a breast-sparing lumpectomy plus radiation or a mastectomy? The outcomes are the same, but the benefits need to be balanced against the risks of radiation and the cosmetic effects. Should the physician make the recommendation? In doing so, does he in fact “tell the patient what is going to happen next”? The decision-making process in the office has become more complicated and, at the same time, more appropriate. In decades past, physicians were taught and patients expected a paternalistic mode of care. “Mr. Smith, you have a small prostate cancer that can be cured with surgery. You may be impotent and incontinent after surgery but you will otherwise have a normal life-span.” Patients would not often have asked, “Doctor, I am seventy years old. Is it possible that this tumor will not affect my life span or bodily functions if I just leave it alone? I rather enjoy my sex life and not wearing a protective shield in my golf shorts.” Some lawyers want to know and physicians therefore offer to provide the patient with all the required information and allow the patient to make the decision. In this situation the physician makes no recommendations but simply provides the data. In our medical-legal climate, it may become very important to define who actually made the decision regarding a specific treatment program. Patients are placed in the rather ambiguous position of asking for guidance from a medical community that must be careful not to make recommendations or provide direction that unfairly limits the infusion of the personal wishes or characteristics of the patient. Some patients want the doctor to decide what is best for them. However, the doctor is not the patient. For example, the doctor may want the cancer out, period. (Perhaps he has witnessed other cancers in his family, etc.) The patient may be a small-risk taker and psychologically better able to accept living with a small cancer that only might harm his health. It is OK for the patient to ask, “Doctor, what would you do if you were me?” The patient and the doctor must accept the fact that in most medical decisions, the personal characteristics of the patient are not necessarily the same as the those of the physician and therefore the decision responsibility must ultimately be that of the patient. It is the best physician who can provide data and a soft direction that the patient can assess and measure for him or herself. What if the patient cannot decide? Here is the hard part. The physician should suggest that the patient seek a second opinion. The physician should assist in the process. If your doctor gives you a hard time, that should be a major clue that you need a second opinion. Second opinions are very difficult for all parties. It can suggest a lack of patient trust. Doctors have egos that match their malpractice premiums. However, the best doctors will support the second opinion process and offer to continue care of the patient following a supportive opinion. If the second opinion is contrary to the first, the patient will have to decide on a course of action and work with the corresponding doctor. In the final analysis, both the physician and the patient must accept the decision-making responsibility for these life-health-death matters. It is always wise to take some time to review any major healthcare decisions before proceeding. Nearly all patients are capable of participating in the process and nearly all physicians want the patient to participate in the decision process. Considering the number of decisions I have made in the past few weeks, I would appreciate any help my patients wish to provide.