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Saturday, July 7, 2007

Take your cues from him: Patient’s role in medical decision-making

Granny Tiger (not her real name, I assume) wrote perceptively about the role that patients want in medical decision-making. Her comment responds to Dr. R.W. Donnell’s thought-provoking blog post about the ways doctors can think; both appear below.

Dr. R.W. Donnell:
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 counseling 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….

Grannytiger’s reply:

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. 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.

Advice to doctors with Web-savvy patients:
To get a more useful discussion next time with patients, tell them the evidence-based web site/s you respect.

Read one of our informed consent stories, or read more from the source blog post by Dr. R. W. Donnell.

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