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Physician-patient collaboration strategies
"Shared mind" is one approach
While there are uncomplicated patient cases where physician-patient communication is fairly straightforward, such communication also can range to the other end of the continuum involving end-of-life care and related decision-making.
However, in a 2009 JAMA commentary titled "Beyond Information: Exploring Patients' Preferences," Ronald M. Epstein, MD, and Ellen Peters, PhD, suggest that the concepts of patient-centered care and communication, as well as shared decision-making between the physician and patient both "assume that patients can articulate preferences based on stable guiding principles or values."1
"While this may be true in straightforward situations, in novel, unanticipated, and emotionally charged situations, preferences may not be elicited as much as they are constructed shaped by how information is presented and by the opinions of family, friends, and the media," the authors write.
In other words, they include the impact of external factors that ultimately come into play to shape a patient's preferences related to medical care.
"Stable" vs. "constructed" preferences
Epstein, who is professor of family medicine, psychiatry and oncology, as well as director, Center for Communication and Disparities Research, at the University of Rochester Medical Center in New York, tells Medical Ethics Advisor that there is "information about the illness that only the patient can tell you."
The patient may be able to tell a physician something about his or her values, "but you may need to help the patient discover their values, because often people haven't thought about their values quite in that way until they encounter a difficult circumstance," Epstein says.
For example, an upper respiratory infection has a number of treatment options, and "the situation is simple [and] consequences are few," the authors write.
"However, preferences are more likely to be unstable in unfamiliar, high-stakes, and uncertain situations, with potential outcomes that have not been considered or have not been imagined," the authors write.
A more complicated situation, such as prostate cancer, might be viewed very differently by different patients.
"Even though the patients may be well informed, their preferences may be influenced by personal health beliefs one patient may fear that surgery can spread cancer, where the other prefers surgery because he wants all cancer removed; both avoid watchful waiting because doing something is better than doing nothing," the authors write.
The authors also note that "values underlying preferences also may change as patients get sicker."
"If you ask people would they rather win the lottery or have a colostomy, most people would rather win the lottery," Epstein says. "But if you look at how happy people are a year later, in fact, they're equally happy. The people with the colostomy are happy because it saved their lives."
"That is what's called 'affective forecasting'; so, I think that's one thing that clinicians have to help patients with is to [enable] them to understand how they might feel in an unfamiliar and unanticipated circumstance," Epstein explains.
Shared information and knowledge
The authors suggest that "psychology, ethics, and clinical practice guidelines do not offer sufficient guidance concerning how to respect and respond to patients' preferences: How would a physician know whether a patient's preference is stable, shallow, or incoherent? What does it mean for a physician to help patients construct preferences?"
"The shared information is information about values and the physician also needs to share appropriate information about the disease, the prognosis, the treatment options," Epstein says. "And also, the patient may have information that they've gotten from the Internet, from friends, or from another doctor, or from another tradition of healing . . . a chiropractor, an acupuncturist."
"So, by sharing that information, it's really just kind of putting all that on the table. The trick here is that if you try to present all of the information, everyone gets overwhelmed you know, [patients] just can't assimilate it all, so you have to be selective," he says.
That's where, he says, a slight bit of a paternalistic approach may be appropriate, depending on the circumstance. Physicians often make decisions about what specific information to present first, as well as the point at which too much information might be overwhelming.
"I think we do have to make choices like that," Epstein says.
Shared deliberation and shared mind
Shared deliberation, another approach to physician-patient communication, is "a kind of back-and-forth that you need to have in order to come to a choice that most people can readily endorse," he explains.
In the paper, the authors write: "Patient sometimes need help in understanding what they believe and want, especially in unfamiliar circumstances. In this situation, physicians must balance sins of commission (unduly influencing patients' decisions) and sins of omission (allowing patients to misunderstand or consider an incomplete option set).
Epstein describes a simple situation he encountered in which a patient needed an antibiotic that had to be taken four times a day. When the patient heard this, the patient said there was no way he/she would remember to take a pill four times a day. Through a couple of simple questions, he found that the patient would rather have a more expensive, but once-a-day regimen with another antibiotic.
He describes that as a "simple decision."
A more complex question might be, "Do you want to try another course of chemotherapy, even though it only has about a 5% chance of helping you?"
"That would be a more complex kind of decision," Epstein says. "That kind of deliberation the back and forth means . . . sharing power, to some degree, but also not burdening the patient with too much responsibility."
Another approach he describes as "shared mind," or "a sense that this decision is not my decision, or it's not your decision, but it's kind of an idea that comes out of the dialogue that neither of us completely owns," Epstein explains.
"I think with shared decision-making, it really works well when you don't feel like it was my decision, or the doctor's decision, but rather that it's somehow shared," he says.
But that level of shared decision-making is "not necessary all the time," he says, "especially when situations are familiar, straightforward, and values are shared."