An interesting and pertinent article describing my own expectations and problems with communicating jointly with my quite friendly and congenial primary care physicians of the past decade or so. Like the case made below, I too, have not been convinced of the joint decision-making process which the medical profession has been advocating. So, what is the problem?
or over a generation now, efforts to make health care more patient-friendly have focused on getting patients and doctors to work together to make decisions about care and treatment. Numerous research papers, conferences and advocacy organizations have been devoted to this topic of “shared decision-making,” and even politicians have clambered aboard the train, devoting several provisions in the Affordable Care Act to “preference-sensitive care.”
But one thing has been missing in nearly all of these earnest efforts to encourage doctors to share the decision-making process. That is, ironically, the patient’s perspective.
Now a study published in the most recent issue of Health Affairs has begun to uncover some of that perspective, and the news is not good. In our enthusiasm for all things patient-centered, we seem to have, as the saying goes, taken the thought of including patient preferences for the deed.
Systemic changes to increase shared decision-making must be addressed as well. Care organizations and doctors’ practices must be restructured to allow more in-depth conversations; clinicians need to be reimbursed for the time required for more meaningful conversations; and health care systems must adopt rigorous quality standards that measure and value real patient engagement in decisions.
The researchers conducted several focus groups with 48 patients from five primary care physicians in the San Francisco Bay area. First, they showed the patient participants a short video on several equally effective but very different treatment approaches for a heart ailment. Then, they asked them questions about what they did with their own doctors when faced with a choice among several treatment options that might be equally effective but could differ in lifestyle effects, cost or range of complications. Finally, the researchers asked the participants if they were comfortable asking doctors about different treatments, discussing their values and preferences or disagreeing with their doctors’ recommendations.
The participants responded that they felt limited, almost trapped into certain ways of speaking with their doctors. They said they wanted to collaborate in decisions about their care but felt they couldn’t because doctors often acted authoritarian, rather than authoritative. A large number worried about upsetting or angering their doctors and believed that they were best served by acting as “supplicants” toward the doctor “who knows best.” Many also believed that they could depend only on themselves for getting more information about treatments or diseases. Some even said they feared retribution by doctors who could ultimately affect their care and how they did.
The findings fly in the face of previous optimistic assumptions about shared decision-making that were based mostly on studies that examined physicians’ intent, but not patient perceptions. “Many physicians say they are already doing shared decision-making,” said Dominick L. Frosch, lead author of the new study and an associate investigator in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute in California. “But patients still aren’t perceiving the relationship as a partnership.”
Interestingly, most participants in this study were over 50, lived in affluent areas and had either attended or completed graduate school. “It’s hard to think that people from more disadvantaged backgrounds would find it any easier to question doctors,” Dr. Frosch said.
Read it all.