Patient power: Docs learn to share control for better outcomes

‘Enhanced autonomy’ gives patients choices and advice

"Patient empowerment" is one of those feel-good buzzwords of the ‘90s. But if patients make decisions, what is the role of the doctor?

To answer that question, a new model of patient autonomy has emerged, and it is reshaping the relationship between patients and physicians. Instead of deciding what is best for patients, physicians now are urged to provide advice and dialogue. Research shows that patients who are given choices and a sense of control are more likely to comply with medical advice, leading to better outcomes and greater patient satisfaction.1,2

"It’s not that the doctor is giving up control," says Michael L. Millenson, a consultant with William M. Mercer of Chicago who specializes in quality of care and patient empowerment. "It’s that the doctor is sharing control for a better outcome. Sometimes that’s difficult for physicians, given the way they’re socialized and trained. But it’s the wave of the future."

This patient empowerment movement rejects the old paternalism, in which physicians simply tell patients what to do and expect them to do it. But autonomy advocates also warn of the other extreme, in which physicians tell patients all possible treatments and avoid showing any preference toward one or another. By giving patients too much independence, physicians are abdicating their role, says Timothy E. Quill, MD, an internist and professor of medicine and psychiatry at the University of Rochester (NY).

"Independence is a scary way to make decisions if you feel you’re on your own and you have to make decisions based on your own expertise," says Quill. "It’s missing that professional piece of an experienced physician guiding you."

Quill developed a model of "enhanced patient autonomy," which provides for an active exchange between the patient and physician.3 (For advice on implementing enhanced autonomy, see article, p. 15.) "People need to be well-informed and given choices, but they need to be given some recommendations to go with that, so they at least know what the doctor thinks is the best thing to do," he says.

The autonomy model brings collaboration. It improves compliance because patients now have a stake in their own treatment plan, says Millenson. "You might call it the medical equivalent of profit-sharing," he says.

Informed choice = better outcomes

The first physician to promote this concept of patient autonomy may have been Benjamin Spock, who encouraged parents to make their own decisions based on medical advice. Then women began to take greater control of their childbirth, making decisions about pain control and drugs that speed labor.

The emergence of health care consumerism fueled the trend toward patient autonomy, as did the litigiousness of society. Some physicians felt they would face less risk of being sued if they gave the patient a range of choices, rather than promoting one recommendation, Quill says.

Today, patients can conduct their own search of the medical literature on the Internet and consult with other patients or health practitioners about their ailments. They may enter a physician’s office with their own ideas about possible treatments. (For more information on how patients use the Internet to improve outcomes, see article, p. 16.)

"None of this means physicians are becoming obsolete at all," says Millenson, who is a visiting scholar at Northwestern University’s Institute for Health Services Research and Policy Studies in Chicago. "It does mean in a way their job is becoming more challenging."

If patient involvement is nurtured, then physicians may discover greater compliance even from some of their difficult cases.

In a study of severely obese patients, researchers at the University of Rochester found that autonomous motivation was linked to greater weight loss and long-term maintenance of weight loss.1 Medical staff gave autonomous support by offering patients choices, telling them rationales for treatments or recommendations, and acknowledging their feelings and perspectives, says Geoffrey C. Williams, MD, PhD, an internist and assistant professor in the University of Rochester’s department of medicine and psychology.

"Physicians need to be aware of patients’ psychological need for being involved in their own care," he says.

In another study, diabetics who charted their own blood-sugar levels over time were more successful in bring them down to normal levels. "For the first time in my practice in 20 years, I had many patients coming to me and saying they wanted to see how they could [make] their blood levels change," remarked Larry V. Staker, MD, director of clinical quality improvement for Intermountain Health Care, a Salt Lake City-based health maintenance organization. (For more information on this study, see Patient Satisfaction & Outcomes Management, February 1996, p. 20.)

In a study of patients with chronic back pain, those with physicians who emphasized self-care and infrequently prescribed pain medication and bed rest had similar long-term outcomes at a lower cost. The patients reported greater satisfaction with patient education.4

Physicians with a collaborative style also had happier patients, another study found. About a third of patients whose physicians rated in the lowest quartile for having a "participatory decision-making style" switched doctors within 12 months — twice as many as switched from doctors rated highly for that skill.2

"Having your patients feel empowered is likely to make them more loyal to you and your practice," says Millenson.

With the gatekeeper approach of managed care organizations, the target group for the "enhanced autonomy" model is the primary care physician, Quill says. Because the primary care physician monitors and manages a patient’s total care, it is especially important for that doctor to adopt a collaborative style, he says.

Physicians can begin simply by nurturing open communication. In other words, physicians need to be willing to hear about psychological and social issues the patient is facing, not just biomedical symptoms, Williams says.

"They need to be sure to listen to what the patient has to say," he says. "When they’re giving them advice, they need to check back to see if the patient has heard and to see if they can do what they’re asked. How is the patient dealing with it all? What does this mean to [providers]?"

The physician’s attitude needs to be nonjudgmental. "It needs to be honest and clear," Williams says.

Colleagues, psychiatrists provide feedback

Physicians can get feedback about their collaborative style from their colleagues in a group practice or even by seeking advice from a psychiatric colleague, Quill suggests. "It’s wonderful to talk about a patient you’re struggling with on a number of issues," he says. "You may come up with ideas you wouldn’t think of as an individual."

Patient satisfaction surveys often give an indication of how well patients feel they communicate with their physician. If you use videotapes to evaluate your patient encounters, make sure you’re focusing the decision-making process as well as history-taking, Quill says.

Most importantly, physicians should acknowledge that this is an area that deserves attention.

"Physicians spend an enormous amount of time talking to people and interviewing them and deciding what the treatment should be," he says. "We should refine our skills [of communication and collaboration] just as we refine our mechanical skills."

References

1. Williams GC et al. Motivational predictors of weight loss and weight-loss maintenance. Journals of Personality and Social Psychology 1996; 70:155-126.

2. Kaplan SH et al. Characteristics of physicians with participatory decision-making styles. Ann Intern Med 1996; 124:497-504.

3. Quill TE, Brody H. Physician recommendations and patient autonomy: Finding a balance between physician power and patient choice. Ann Intern Med 1996; 125:763-769.

4. Von Korff M et al. Effects of practice style in managing back pain. Ann Intern Med 1994; 21:187-195.