A couple of weeks ago I wrote a post which was triggered by two conversations I had had with friends who had recounted to me tales in which it appears their doctors were not willing to entertain their own thoughts about their symptoms. As I detailed, both of them put forward (I think) utterly reasonable, logical and plausible explanations for their symptoms, only to be rebuffed by their doctors who then put (in my opinion) much less likely explanations forward. Both my friends, were quite dissatisfied with the outcome of their consultation, and understandably so.
I was reminded of this when reading, this week, about a piece of research which appeared in the Archives of Internal Medicine . In this study, researchers sought to ascertain individuals’ attitudes and beliefs about the doctor-patient relationship and the decision making process. Here’s an excerpt from the introduction to the study:
Effective patient-physician communication is essential for shared decision making, considered by some to be the “pinnacle” of patient-centered care. Many health care decisions have multiple options and no correct choice. These are called preference-sensitive decisions, and the optimal decision is one that takes into account patient preferences and values in a collaborative process with the physician, known as shared decision making. We sought to describe patients’ intentions to engage in shared decision-making communication behaviors in response to a hypothetical preference-sensitive clinical scenario and to examine the effects of underlying patient beliefs on these behaviors.
The study participants were presented with a hypothetical situation regarding the treatment of cardiovascular disease, and then asked several questions. The great majority (more than 90 per cent) were prepared to ask questions and discuss preferences. However, it was a different story when it came to disagreeing with the doctor. Here, only 14 per cent of people said they would be willing to challenge the doctor’s opinion, often for fear of being labelled a ‘bad patient’. The ‘risk’ here, of course, is that a patient will simply not comply with the doctor’s recommendations, but the doctor may well not know this is the case. Also, the lack of openness here can only really compromise the relationship, I think, and erode the likeliness of a good outcome.
While looking at this piece of research, I found my way to an organisation called the Informed Medical Decision Foundation based in Boston, Massachusetts, US. This organisation funded the research described above and, it appears, is deeply committed to patient advocacy. You can see a short video featuring patients and doctors connected with the programme here.
To be honest, I’m delighted that such an organisation exists, and especially delighted that there are doctors who appear to be mindful of the importance of involving their patients in the decision-making process.
Sometimes, it makes sense for a patient to defer to their doctor. I remember having a discussion one day with a friend of mine who is an anaesthetist. He pointed out, quietly rightly, that patients are generally not the best people to determine which anaesthetic agents he uses – that’s his job. However, there are clearly many situations where, as the authors of this recent study point out, there is not a clear or singular option, and it does make sense to take into account a patients views and preferences when deciding on management.
I hope the Informed Medical Decision Foundation and the concept of shared decision making gets the attention it deserves. I also hope that more doctors ‘get with the programme’. In a way, I sense some doctors will be forced to embrace this way of doing medicine. Otherwise, they risk have dwindling positive impact on their patients, as well as dwindling numbers of patients.
One of the doctors attached to the Informed Medical Decision Foundation (Dr Michael Barry) recently co-authored a piece in the New England Journal of Medicine about shared decision making which you can read here.
This piece points to research in which improved outcomes and perhaps reduced burden on healthcare services. Here’s an excerpt:
Just as there are randomized trials of tests and treatments, there have been randomized trials of shared decision making supported by patient decision aids. According to the latest Cochrane review of 86 trials published through 2009, the use of patient decision aids for a range of preference-sensitive decisions led to increased knowledge, more accurate risk perceptions, a greater number of decisions consistent with patients’ values, a reduced level of internal decisional conflict for patients, and fewer patients remaining passive or undecided.The use of decision aids is also associated with patients’ choosing prostate-specific–antigen tests for prostate-cancer screening and major elective surgery less often, which suggests that shared decision making could be a tool to help address the problems of overdiagnosis and overtreatment.
The piece ends with this paragraph:
If we can view the health care experience through the patient’s eyes, we will become more responsive to patients’ needs and, thereby, better clinicians. Recognition of shared decision making as the pinnacle of patient-centered care is overdue. We will have succeeded in building a truly patient-centered health care system when an informed woman can decide whether to have a screening mammogram and an informed man can consider whether to have a screening prostate-specific–antigen test without their clinicians labeling the decision “wrong” on the basis of different values and preferences.
Three cheers for these sentiments, I say.
1. Adams JR, et al. Communicating With Physicians About Medical Decisions: A Reluctance to Disagree. Arch Intern Med. 2012:1-2. doi:10.1001/archinternmed.2012.2360