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.