Informed consensus: How to work with patients to achieve positive treatment

Talk may be cheap in the cliche, but not in physicians' offices, where a single discussion on a contentious issue such as hormone therapy or prostate cancer screening can take longer than the 15 minutes allotted for the entire visit.

But discussions about medical options that balance a patient's values, preferences and understanding with therapeutic gain should not be overlooked. There is new evidence that "shared decision-making" can be beneficial to patients and physicians.

For starters, such discussions might enhance compliance.

Peter Ubel, MD, an Ann Arbor, Mich., internist and director of the University of Michigan's Program for Improving Health Care Decisions, says he is likely to prompt a discussion on hypertension medication by asking his patient, "Why do I care about your blood pressure?"

"It's a great way to see what their understanding is about their risk factors," he says. Some patients equate hypertension with emotion and believe if they don't feel pressured or tense they don't need to take their pills. "If you want patients to take their pills every day, it's good for them to understand why."

Shared decision-making is a trend that appears poised to follow informed consent as an important standard of care. At the very least it can help physicians and patients find a comfortable perch along a continuum that ranges from physician paternalism to patient autonomy.

Its momentum is propelled by several forces.

One is the baby boomers who came of age questioning authority. "In the '50s when I grew up, professionals -- doctors, lawyers, policemen, priests -- were considered gods," says Annette O'Connor, PhD, professor at the University of Ottawa's Faculty of Health Sciences. "Certainly the baby boomers didn't go for that."

The ease of obtaining medical information from the Internet is another driver, as is the growth of research on evidence-based medicine. "We realized that if you really want evidence-based practice you need to not only inform the professionals, but you need to inform patients," Dr. O'Connor says.

The U.S. Preventive Services Task Force, an independent panel of physicians established by the federal government to weigh evidence-based recommendations on a wide range of clinical and preventive services, supports increased physician-patient give and take. The task force defines the shared decision-making approach as a process in which both the patient and clinician share information, participate in the decision-making process and agree on a course of action.

The panel and its public health counterpart, the Centers for Disease Control and Prevention's Task Force on Community Preventive Services, published studies in the January American Journal of Preventive Medicine that Dr. O'Connor calls "landmark documents."

Weighing pros and cons

In its study, the USPSTF concluded that shared decision-making is essential for crafting recommendations to patients about medical interventions that have benefit for some patients but not all. The panel found that it may be especially useful in the following situations:

• Helping patients and their physicians decide whether to use a preventive service that has a net benefit but also carries the potential for harm. An example is aspirin therapy that is valuable in preventing heart disease but can also cause stomach bleeding.
• Deciding which of several equally acceptable screening options are appropriate for a patient. An example is colorectal cancer screening, in which five choices are available, including flexible sigmoidoscopy and colonoscopy.
• Re-evaluating a therapy for which new scientific evidence calls for a reversal in recommendations. An example is hormone therapy in which recent findings from the Women's Health Initiative are prompting renewed discussions over the pros and cons of hormone use.

The CDC panel focused on cancer-screening decisions in its report and found that brochures and Web-based information that individuals can access independently helped them make good individual choices about cancer screening, including whether to be screened at all.

Shared decision-making might lead to treatments that are more consistent with patients' preferences and values, concluded Peter Briss, MD, MPH, lead author of the CDC study. "There is increasing recognition that medical tests, procedures and approaches aren't one-size-fits-all."

Improved communication also could lead to a more satisfying therapeutic relationship for both physicians and patients, Dr. Briss says. But physicians should recognize that some patients would rather not take part in a medical decision. "There are certainly people who would prefer to delegate the decision-making back to the physician and that's perfectly OK. But people ought to have the option."

Michael Fleming, MD, a family physician in Shreveport, La., and president of the American Academy of Family Physicians, has been practicing this shared-decision process for a long time, and considers it a regular part of medicine.

For example, a recent office discussion on the benefits of statins included demonstrating to a patient that taking vitamin E supplements, a heart-healthy treatment promoted in magazine and newspaper articles, wasn't sufficient in his case. "I wrote him a prescription for a statin," said Dr. Fleming. "I think he'll take it. He's been a patient of mine for several years."

But the collaboration also can lead to compromise, Dr. Ubel says.

Consider the management of diabetes. "Just how often do patients want to stick their fingers?" he asks. "Just how many times do they want to inject themselves? Maybe they'd rather have an easier regimen and let their control drift a little higher."

"This is where I probably differ from a lot of other doctors," Dr. Ubel says. "To me the end point is not just medical. It's about their life."

Often times, the paradigm of shared decision-making is associated with a one-time monumental decision, Dr. Ubel says. For breast cancer, it might be mastectomy versus lumpectomy. For heart disease, it could be surgery or no surgery. "But I think a lot of shared decision-making is subtler than that and occurs over time. It's not just a one-time decision."

Patient education aids

Although a physician can supply a great deal of valuable and persuasive information to convince a patient that something is in their best interest, Brooke Herndon, MD, an internist in Lebanon, N.H., finds that the patient isn't always swayed.

Dr. Herndon remembers a patient who refused to take a tilt table test to help diagnose an episode of fainting. "We kept going around and around," said Dr. Herndon. "I don't usually push people to do tests, but I felt I really needed the result."

Dr. Herndon referred her patient to the Center for Shared Decision Making at Dartmouth-Hitchcock Medical Center, also located in Lebanon, to fill out a written decision guide to help determine why she was so opposed to the noninvasive test. But the patient didn't change her mind.

"I said, well that's her decision. In the end I felt I'd done my best job and the decision we ended up with was as good as it was going to get."

Dr. Herndon has turned to the center for help before, especially when explaining the prostate cancer screening or screening for ovarian cancer -- both of which can raise more questions than they answer.

She trusts the resources that the center supplies. But she also views all the material before recommending it.

"I'll initiate the discussion at a visit and ask patients to [look at material from the center] and then get back to me and we'll talk more," Dr. Herndon says. Research has shown that follow-up discussions are greatly sharpened and focused when decision aids are used to cover the basics.

Adam J. Schwarz, MD, also a Lebanon, N.H., internist, says the center's resources help "nudge people into behavioral change, whether it's adherence to medical therapy or embarking on a smoking-cessation effort."

In addition to promoting treatment adherence, a patient's willingness to join in the process and assume responsibility for a medical decision can often "take the monkey off your back," Dr. Schwarz says.

There is an ever-increasing number of aids that can be used by patients in consultation with their physicians to arrive at a decision about treatment options. The Dartmouth-Hitchcock Center is one repository. Others include the Mayo Clinic in Rochester, Minn., and the Ottawa Health Decision Centre in Canada.

Dr. O'Connor's research associated with the Ottawa Centre found that physicians were motivated to use the materials with their patients because the resources helped to avoid repetitious discussions as well as extra calls from patients seeking additional information. The physicians also felt more comfortable regarding liability issues by having better-informed patients.

These patients also were less likely to favor aggressive surgical procedures in favor of more conservative approaches, Dr. O'Connor says. "Basically, if a patient gets a decision aid, they hang onto their ovaries, their breasts, their prostates and they have less back surgery."

Physicians' decisions to use well-designed and informative decision aids make sense to Dr. Briss.

"It's perfectly clear to me that we can't expect heroic single providers to do all of this work in the context of a 15-minute office visit."