In my last post, I talked about the uncertainties of medicine, and suggested that the relationship between doctor and patient must be built on trust. (See “A Transaction Based On Trust”). I argued that this is why the consumer-driven model of medicine doesn’t work. It assumes that the doctor is a retailer selling his services and that as his customer the consumer must demand the best quality care at the lowest price. Immediately the relationship between buyer and seller begins to sound adversarial, just as it is in the commercial marketplace where “caveat emptor” always applies.
But the health care market is not like other market places, and the doctor is not a retailer. He or she is a professional who has taken a pledge to put the patient’s interests ahead of his own interests. For the transaction to go forward, the patient has to believe this. Who would go under the knife, or submit to any painful or invasive procedure if he didn’t trust the doctor?
At the end of that post, I asked, “But what about the uncertainty of medicine. Does this mean that the patient must simply trust that his doctor has “the right answer?”
Not at all. The relationship between patient and doctor must be based on mutual trust. Just as the patient trusts the doctor to act as a professional, the doctor needs to trust the patient enough to be open with him about the uncertainties of the patient’s condition and the pros and cons of the treatments that they are considering.
Sometimes—but not always—the doctor must tell the patient: “In this particular case I can’t be sure what the best treatment would be. But here are the options and here are the risks and benefits of each.”
This isn’t consumer-driven medicine, but it is “patient-centered
medicine.” The patient and doctor share in the decision making
as—together—they confront the ambiguities of medicine. What the doctor
brings to the table is his scientific knowledge, and his experience,
over the years, treating patients suffering from a similar illness.
What the patient brings to the table is his own values, priorities and
I’ve written about shared decision making here, in an article
where I focus on doctors and patients collaborating as breast cancer
patients decide whether to have a mastectomy or a lumpectomy, while
patients who have been diagnosed with early-stage prostate cancer
decide whether they want to be treated or whether they would prefer to
wait and see how quickly the cancer progresses.
“Shared decision making” is a formal process that has been developed at
a number of hospitals around the country. Dartmouth-Hitchcock in
Lebanon, New Hampshire led the way in 1999 when it opened a Center for
Shared Decision Making where doctors and decision-making coaches
learned to use various “decision-making aids” to help patients weigh
their options. (See their website here).
These aids include pamphlets that spell out the risks and benefits of
various elective tests and procedures as well as videos featuring
patients who describe how they went about making the decision—and
whether they are happy with the outcome.
Patients take these pamphlets and videos home, and often view the
videos more than once, with their families. When they go back to the
doctor, he or she asks questions to test whether the patient fully
understands the benefits and risks. If the patient seems confused, the
doctor explains further until, as one doctor puts it—“Suddenly, the
patient’s face clears—and you know they understand.”
At that point, the doctor begins to ask the patient questions about his
own preferences, fears and priorities. Are there certain side effects
that he fears more than others? Is he a risk-taker? How does he feel
about uncertainty? Is the breast cancer patient’s first priority to try
to preserve her breast or would she prefer to “get it over with” by
having a mastectomy? The treatment that might be “right” for one
patient will not be right for another.
Here the patient becomes an active participant in the decision-making
process. In the past, we talked about patients giving “informed
consent” before any elective procedure. At the decision-making
center, patients make an “informed choice” that takes their own values
and temperament into account.
At Dartmouth, experts in shared decision-making say that in the end,
the final decision does not have to be made by the patient. After
assimilating the information about benefits and possible
complications—and expressing his own fears and preferences—some
patients want the doctor to weigh in. Here, strict advocates of
“patient autonomy” argue that only the patient can know what he or she
wants. If a patient asks for help, the physician is supposed to say: “I
don’t know John, I’m not you.”
But at Dartmouth, decision-making coaches recognize that while it is
important that the patient participate in the process and become fully
informed, it can be cruel to refuse to give him advice at the end of
the process. A doctor who steps away at that point could be seen as
“abandoning” the patient.
Moreover, in the case of prostate cancer, if the patient trusts the
doctor, he may be willing to listen to the doctor who tells him that
“doing something now” may not be the best course of action. The notion
that “more care is better care,” and that the newest, most expensive
treatment must be best is deeply ingrained in our consumer culture. And
it’s one reason why our health care costs are so high.
The goal of shared decision-making, by contrast, is to “give the right
care to the right patient at the right time.” Just because the doctor
tells the patient that he is a candidate for a particular elective
procedure–whether it’s a knee implant, angioplasty, or spine
surgery—doesn’t mean that he should have that surgery. This is where
the patient’s preferences come into play.
Perhaps it should come as no surprise that when patients have a chance
to consider the benefits, risks and uncertainties of elective
treatments—and make a choice, rather than simply “consenting”–twenty
percent of more decide not to go ahead with the procedure. For obvious
reasons, patients just aren’t as enthusiastic about surgery as surgeons
are. A good surgeon is proud of his craft, and wants to help as many
people as possible. But the patient is also thinking about how long it
will take to convalesce, how painful it will be, whether he or she can
afford to take time off work, the possible risk that something will go
wrong . . .
Typically, the patient who decides against an elective procedure says
something like, “You know what, my knee doesn’t hurt that badly. I
think I’ll wait and see.” Dr. John Wennberg, co-founder of Dartmouth’s
Center For Shared Decision Making, will be publishing an article about
this research in the November issue of Health Affairs.
Finally, let me suggest that while an “educated consumer” cannot bring
down health care costs, the “informed patient” could help rein in
health care spending. Let me be clear: saving money is not the goal of
shared decision-making. The goal is quality, and here I would define
high quality care as care that gives “every patient as much as he
needs—and no less” while also giving each patient “as much as he
wants—and no more.”
In other words, the goal is to avoid both under-treatment and the over-treatment that plagues our health care system.
But while the goal is not to cut costs, saving money is certainly a
welcome by-product of shared decision making. And once again, we see
that lower cost and higher quality go hand in hand.
By contrast, consumer-driven medicine is likely to push health care
spending ever higher for a number of reasons. First, the patient who
views himself as an “empowered consumer” is likely to feel that there
must always be a right answer. He is not tolerant of ambiguity. And he
believes that, as a savvy shopper, he can find that right answer. If
his doctor doesn’t have the cure, it’s because he’s not keeping abreast
of the latest developments. But the consumer is convinced that he can
find someone who will have the answer, and who will do something now.
And chances are he will.
The patient who sees himself as a consumer also is likely to be easily
influenced by “direct-to-consumer” television ads. Unfortunately,
research shows that DTC ads tend to tout the newest, most expensive
drugs—products that the manufacturer would have a hard time selling
“direct to the doctor” because he doesn’t yet have the evidence to show
that they are effective, and that, long-term, the benefits outweigh the
The well-informed patient, on the other hand, appreciates the grey
areas of medicine. His doctor has been open in describing the
uncertainties. As a result, this patient is more willing to accept
answers like “We don’t know.” Or, “It depends.” And he is more likely
to listen to a doctor who tells him that the most aggressive approach
is not necessarily the best approach. He is more likely to hear a
physician who says: “Try physical therapy first. Try drug therapy. Try
a change of diet and exercise.”
This is why I think that, if doctors and patients work together, they
can contain the cost of health care, paving the way for a sustainable,
affordable, health care system that offers the right care to the right
patient at the right time.