Thursday, July 28, 2005

Patient participation in medical decisions: Is it evidence-based?

Yesterday DB of DB’s Medical Rants blogged about patients participating in treatment decisions, citing this article in the Journal of General Internal Medicine. Interestingly, the study found that about half of patients surveyed would rather the physician make final decisions. He makes the point, and I agree, that we should allow patients to be involved to the extent they wish. But I would caution that unless we apply rigorous principles of evidence-based medicine to the discussion with the patient, the decision making process becomes flawed. So if patients’ decisions need to be evidence-based just as doctors’ decisions do how do we bring that about? Is there enough time in our busy practices to do it?

Consider these case examples. You are counselling your patient about upcoming knee replacement. You plan to give enoxeparin for DVT prophylaxis. How do you inform the patient? Sure, you know that it’s the right thing to do and all the experts recommend it, but the patient deserves evidence. So, you do a Pub Med search (or, somewhat more easily, consult a filtered resource such as Up To Date) and cull out the studies you critically appraise as valid and applicable to your patient. In order to advise your patient on the magnitude of benefit of the proposed treatment you look for, or calculate the absolute risk reduction (ARR) for the proposed treatment as well as the absolute risk increase (ARI) for bleeding. In order to translate this into language the patient can understand you then, from the absolute risk reduction for DVT and the absolute risk increase for bleeding, calculate the number needed to treat (NNT) and number needed to harm (NNH) respectively. You then have the discussion with the patient, modifying it as necessary to take into account any unique attributes of your patient which might increase bleeding risk. If the patient is to be discharged early after the surgery you must also provide information concerning the cost of continued enoxeparin at home, taking into account the patient’s financial condition and payer sources. Then you ask the patient and any concerned family members if they have questions, answer them as they arise, and document your discussion in the medical record. Time consuming, eh?

Of course if this is not your first patient to receive enoxeparin for orthopedic prophylaxis maybe you’ve done the drill before, but the discussion still takes a lot of time. And your next patient may present a clinical problem you haven’t researched in the last couple of months. Let’s say you’re discharging a patient after an acute coronary syndrome (ACS). You want to put the patient on a statin drug because you know it’s a good thing to do and you are going to explain it to the patient. To merely say “this is good for you” or “here, take this pill because it will decrease your risk of another heart attack” might sound paternalistic in this day of medical consumerism. So, again, you must present the patient with evidence. You do the search and find a raft of studies, from which you choose the ones of the highest level of evidence and applicability to your patient. As you critically appraise the studies you ask how the study in question applies to your patient. How do the lipid entry criteria and average lipid levels of the study patients match up with your patient’s lipid results? What is the number needed to treat and the number needed to harm (your patient tells you a friend of hers heard that cholesterol lowering medications could destroy the kidneys)?

Your next patient arrives from the nursing home with severe sepsis. As multiple concerned family members attend the patient and ask numerous questions you are considering whether to give activated protein C. You are aware of the positive results of the PROWESS study, but are concerned about the risks of serious bleeding. You are aware of the strict and very detailed inclusion criteria for patient selection, and you’ve heard of some recent controversy that has arisen concerning the use of activated protein C, and you need to explain it all to the family. You are already behind schedule after the long discussion with your previous patient about statin drugs.

What’s a doctor to do? I have no pat answer. Our patients deserve to be included in decision making but if they participate they must have the high quality and specificity of information they need to make valid choices.

4 comments:

rglacsamana said...

I practiced General Internal Medicine for 33 years, and in my experience, the vast majority of my patients were reasonable people willing to listen and ask questions, which I encouraged them to do.

I made sure I spent at least five minutes with them discussing all options - whether for diagnostic testing and procedures, or for treatment. Occasionally, I would
suggest a second opinion in instances where there might be controversies.

In the end, however, most of them deferred to what I felt would be the best course, a reflection I believe of their confidence in my judgment since I have taken care of them for so many years.

Oh yes, it's absolutely necessary to be well-informed and to keep up-to-date with the latest since
things we held sacred yesterday would not necessarily be true today. We may be spending more time
in these interactions, but I see no better way to satisfy patients
today who are better informed and want to exercise some control on what we do for them.

grannytiger said...

My goodness. If my physician went to all that trouble for me, I'd require resuscitation from the shock. But to tell you the truth, such extreme conscientiousness -- while I applaud it -- is not only impractical in terms of time (yours!) but also overestimates by a long shot what most patients would expect in terms of empowerment. We certainly want to be informed but there are much less time-consuming ways to help us achieve it. For example, point that ACS patient to web sites you recommend containing reliable information on statins that he can understand (also tell the patient which types of web sites to steer clear of when it comes to any medical information.) Offer a pamphlet on DVT prophylaxis to the knee replacement patient. You probably already have a pretty standard informed consent "spiel"; give the patient that, and then take your cues from him. If the situation warrants, make a quick diagram of his anatomical problem and what the proposed treatment will do. If he is one of the relatively few patients who really seem to need the specifically tailored information you describe, fine. But most of us will not. As long as we know you are open to answering questions, even ones we think of after we leave the office, most patients feel that we have a role in the decision-making process.

Ken Farbstein said...

Thank you for showing patients how intricate physicians' thought processes and patient communication can be.

A story about what can happen when a doctor does NOT inform patients clearly, e.g., about surgical risks, appears at http://www.patientsafety.blog.com/2007/01/how-could-billy-have-known.html.

Kees Bakker said...

A few years ago, I (with a background in general practice)was accepted into anaesthetics training and I understood that the department was curious about my supposedly skilled communication techniques.

Surprisingly, I discovered that while patients are delighted to discuss the pro and con subtleties of taking aspirin, when it came to weighing the merits of different methods of anaesthesia their opinion was a uniform 'just knock me out, doc'.

I have the suspicion that there's a lesson in this, but I'm not sure what it is.

K. Bakker