In Loco Parentis
Abstract & Commentary
By Allan J. Wilke, MD
Professor and Chair, Program Director, Department of Family Medicine, Western Michigan University School of Medicine, Kalamazoo
Dr. Wilke reports no financial relationships relevant to this field of study.
Synopsis: Primary care physicians have a great opportunity to improve their discussions with their patients about cancer screening and the treatment of common chronic diseases.
Source: Fowler FJ, et al. How patient centered are medical decisions? Results of a National Survey. JAMA Intern Med 2013;173:1215-1221.
How do we involve patients in decisions about their health care? This study from the Informed Medical Decisions Foundation attempts to answer the question using the results of a survey conducted between 2010 and 2011 with a probability sample from across the United States. The subjects were all older than 40 years, and indicated that in the previous 2 years they were screened for cancer (colorectal, breast, or prostate); were treated for a chronic illness (hypertension, hypercholesterolemia, or depression); had surgery (for knee or hip replacement, cataract removal, or low back pain); or had discussed any of these conditions with a health care provider.
The survey asked four questions. The blanks were filled in by the condition that the patient had previously identified.
1. How much did you and the health care provider(s) discuss the reasons you might want ____?
2. How much did you and the health care provider(s) discuss the reasons you might not want ____?
3. Did the health care provider(s) explain to you that you could choose whether or not to have ____?
4. Did the health care provider(s) ask you whether or not you wanted to have ____?
The answers for #1 and #2 were limited to "a lot," "some," "a little," and "not at all" and questions #3 and #4 to " yes" or "no."
A total of 2718 subjects completed the survey. If a subject had identified more than one decision, only two were considered. About one-fourth made only one decision. The demographics varied by problem, as might be expected (e.g., gender differences for prostate and breast cancer and age differences for patients contemplating cataract surgery). There were some interesting differences: Women were more likely to have discussions about depression medications, college graduates were more likely to discuss cancer screening, and whites were more likely to discuss cataract surgery. Younger women had more discussions about mammography and depression medication than older women.
In general, across all 10 conditions, there were more discussions about the "pros" than the "cons" of a medication or a procedure. For example, almost 80% of patients reported that there was "a lot" or "some" discussion of the advantages of antihypertensive medications, and less than 30% remembered "a lot" or "some" discussion of the drawbacks. The ratios of "pro" to "con" discussions were most dramatic for breast (7.6:1) and prostate cancer screening (5.7:1) with colon cancer screening (5:1) not far behind (no pun intended). The most "fair and balanced" discussions were around low back surgery (1.2:1). Taken as a group, surgeons performed better than primary care physicians.
COMMENTARY
Are there any primary care physicians in the United States who aren’t preparing their practices for Patient-Centered Medical Home (PCMH) certification? It’s right up there with motherhood, the flag, and apple pie. Part of the foundation of the PCMH is shared decision making (SDM),1 so it was very disappointing to see how poorly we did in that area, especially compared to our surgical colleagues. Maybe all the years of getting surgical informed consent has given them an edge, or maybe having to deal with "failed back" patients has given them incentive to emphasize the risks up front. It is possible that the patients just didn’t remember our conversations or that it was a different physician who ordered the medications and the screening tests, and they’re to blame, not us, but I don’t think so. In particular, it was surprising to see how infrequently our patients remembered a discussion of the downsides of breast and prostate cancer screening, especially since there is controversy surrounding both, and the debates have reached the media. I suspect that it wasn’t the patients’ memories that suffered. It is time consuming for physicians to lay out all the complex variables and decision pathways, but it really isn’t an informed decision if we don’t.
This study raises questions that will have to wait for future investigations. Are men uncomfortable discussing depression? Do doctors know how to initiate that discussion with men? What role do class, socioeconomic status, education, and age play in SDM? Why do physicians downplay the risks of medicine? Is it because their source of drug information is people who want them to prescribe their company’s products, or do they think that patients’ knowledge of the risks will make them more likely to refuse the therapy?
What are some other barriers to SDM? One is that our patients and we operate under a "doctor knows best" paradigm. In the same issue of JAMA Internal Medicine, Tak and colleagues reported that "96.3% of patients expressed a desire to receive information about their illnesses and treatment options," but "71.1% of patients preferred to leave medical decision making to their physician."2 While it is mostly true that we have a better knowledge of medicine than our patients (they do access the Internet), medical knowledge is only one part of SDM. Sometimes, even being a doctor is not enough, as Dr. Lisa Rosenbaum describes in her article "How Should Doctors Share Impossible Decisions with Their Patients?"3 If you’ve never heard of the "affect heuristic" or understand the roles that risk aversion and disgust play in decision making, I recommend you give it a read.
I think another major barrier is trying to apply studies done on populations to the patient sitting in front of you. Yes, atorvastatin can reduce the risk of heart disease by 16.5% in the elderly with heart disease,4 but how do you respond to the 45-year-old woman with no heart disease and a sky-high cholesterol when she remarks that she saw a commercial for Lipitor® and wonders if it’s the drug for her? What do you tell the 85-year-old man with a blood pressure of 160/90 who loves potato chips and has poor bladder control, when he says, "Give it to me straight, Doc. How much time do I have? Will this diuretic really improve my life?" I hope your answer is, "Bet you can’t eat just one!"
References
1. http://www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/pcmh_defining_the_pcmh_v2.
Accessed June 29, 2013.
2. Tak HJ, et al. Association of patient preferences for participation in decision making with length of stay and costs among hospitalized patients. JAMA Intern Med 2013;173:1195-1205.
3. http://www.newyorker.com/online/blogs/elements/2013/ 07/how-should-doctors-share-impossible-decisions-with-their-patients.html. Accessed July 15, 2013.
4. Athyros VG, et al. Statins and cardiovascular outcomes in elderly and younger patients with coronary artery disease: A post hoc analysis of the GREACE study. Arch Med Sci 2013;9:418-426.
