The paternalism is a little more kind-hearted now: Patient's participation in medical decision-making

David Leonhardt tells this story in his column today:
Dr. Dale Collins Vidal, a reconstructive breast surgeon at the Dartmouth-Hitchcock Medical Center, told me a story about a patient's husband who asked to sit in on the medical team's discussion of his wife's case. The doctors said no, because they were uncomfortable with him knowing about the uncertainty surrounding the case. "The paternalism is a little more kind-hearted than it was in the past," Dr. Collins Vidal says, "but it's still paternalism."


As a rule of thumb, Don Berwick suggests "nothing about me without me." This fails the test.

Advice: Patients and their spouses need to learn about the uncertainty that usually accompanies the decision the doctor is making. If this is impossible during a hectic, scary time in the hospital, get a professional patient advocate to help you understand your choices. The alternative is to leave key decisions to well-meaning strangers who don't know your loved one's values and preferences.

Thanks to David Leonhardt for the source story in today's New York Times.

He's the guy with the medical degree: Obama's vision of government's role on treatment options

President Obama outlined his vision for the healthcare system in an interview with Andrew Leonhardt, published in the New York Times Magazine:

Consumers have gotten more active in their own treatments in a way that's very useful.  That should continue to be encouraged, to the extent that we can provide consumers with more information about their own well-being.

When it comes to medical care, I know how to ask good questions of my doctor.  But ultimately, he's the guy with the medical degree.  If my doctor tells me, You know what, you’ve got such-and-such and you need to take such-and-such, I don't go around arguing with him or go online to see if I can find a better opinion than his.

And so, in that sense, there's always going to be an asymmetry of information between patient and provider.  And part of what I think government can do effectively is to be an honest broker in assessing and evaluating treatment options.  And certainly that's true when it comes to Medicare and Medicaid, where the taxpayers are footing the bill and we have an obligation to get those costs under control.  

When Peter Orszag and I talk about the importance of using comparative effectiveness studies as a way of reining in costs, that’s not an attempt to micromanage the doctor-patient relationship.  It is an attempt to say to patients, you know what, we've looked at some objective studies out here, people who know about this stuff, concluding that the blue pill, which costs half as much as the red pill, is just as effective, and you might want to go ahead and get the blue one.  And if a provider is pushing the red one on you, then you should at least ask some important questions.  

Thanks to Andrew Leonhardt for the source article in the NY Times Magazine.

It's our heads under the knife: Comparative effectiveness research on treatment outcomes

I'm in training again toward an ambitious personal fitness goal, and it feels good. That's a real change from a few months back, when I had to stop jogging, biking and rowing because of a nasal condition. Here's the story:

Feeling congested all the time, I saw my primary care doctor. He referred me to an ear-nose-throat (ENT) surgeon for a consultation. The ENT surgeon examined me, and suggested – surprise! – surgery. (Indeed, Jack Fowler of the Foundation for Informed Medical Decision Making says surgeons recommend surgery in most of their consultations.)

I found and read a book on the treatment options for this condition, written by a surgeon who has widely performed this operation. To my surprise, I learned that he has started generally advising patients against this operation. I looked on the Internet to find the comments of patients who had had the surgery, and learned that many patients needed the operation again a few years later. Others reported that their recuperation had been particularly uncomfortable.

Luckily, I learned that an alternative to surgery was available: a steroidal inhaled spray, which has eliminated the congestion. It seems that I don't need surgery.

So now it's springtime, and I can train again, and breathe deep of the fresh air. And there's the fresh air of a new presidential administration. A thousand flowers, and a thousand legislative bills, are blooming.

One big bill would fund and publicize comparative effectiveness research on treatment options. Pres. Obama said that government should serve as an honest broker in helping people assess and evaluate treatment options. As he told interviewer David Leonhardt in Sunday's New York Times Magazine, "[it's] not an attempt to micromanage the doctor-patient relationship. It is an attempt to say to patients, we've looked at some objective studies, people who know about this stuff, concluding that the blue pill, which costs half as much as the red pill, is just as effective, and you might want to go ahead and get the blue one. And if a provider is pushing the red one on you, then you should at least ask some important questions….You have to have some independent group that can give you guidance."

Yes. For the septoplasty et al that I was considering, it would have been helpful to know what fraction of these surgical patients would recommend the surgery to a friend, how many needed the surgery repeated, how uncomfortable the recuperation was, how they rated the long-term improvement in how they felt, and how dangerous it was. The treatment decision is about the clinical quality as patients define it – not as it's usually defined by clinical outcomes researchers.

I hope that the $1.1 billion to be spent very soon on comparative effectiveness research will be spent on outcomes as patients define them. It's our heads that are under the knife…

In buying a car, I first look at Consumer Reports. This esteemed nonprofit routinely surveys car owners and portrays their findings on key dimensions of the cars' quality. We need something similar so that we can become smart buyers of our own healthcare.

Advice: Read widely about treatment options before you make a decision.

Read another story on a treatment decision.