Whose Choice Is It, Anyway?
by Samantha Cunningham
Illustration: “Brain” by Michelle Shi
The Role of Patients and Doctors in Decision-Making
A Patient’s Request
“I need a laparoscopy,” I told my doctor. Sure, I was the patient, and he was the provider, but I already knew how to fix this condition. I had made up my mind that a laparoscopy, an hour-long surgical procedure that involves making two small cuts on the abdomen and removing tissue using a robot and a camera, was the only solution. If this doctor did not agree to the procedure, I would find one who would. After spending a semester teaching students about endometriosis and the importance of advocating one’s own health, I had come to the realization that I had endometriosis. I had all the textbook symptoms. I just needed to convince my gynecologist, who was now fulfilling his role as gatekeeper to my care.
To my dismay, my doctor did not suggest scheduling a laparoscopy right then and there. He was faced with a choice that physicians must make regularly, deciding between the more medically indicated option (trying more pills) and what the patient is requesting (a surgical procedure, with all its risks). Many of us, as patients, are guilty of something like this – how disappointed do we feel when we go to the doctor, sure that we will be sent home with a prescription, but are given the rather bland diagnosis of “virus” instead?
Our doctors cannot prescribe us antibiotics simply because we ask for them, nor can they agree to perform procedures simply because we are confident we need them. American doctors must balance the risks of not following what they consider to be the medically indicated course of action with the risks of having a dissatisfied patient, and because of this balance, there is not always an obvious solution even to a seemingly obvious situation. As technology has better equipped providers to treat serious conditions, patients too have become more knowledgeable about what to expect from their caregivers.
Information Asymmetry in the Healthcare Market
The United States’ healthcare system is meant to work as a free market. In a truly free market, both buyer and seller have equal power, and they both have the power to walk away from a transaction. However, this is not the case when it comes to healthcare. Patients are not expected to come to the exchange with a full understanding of health information, outcomes, and options, meaning that they are reliant on their providers, who are also selling the product, for some of this information.
The power differential between physician and patient is well-established;1 the physician comes to the transaction with more knowledge than the patient. With the advent of the information age, the patient has taken back some of this control, empowered by a wealth of online resources. In a Pew study, more than one-third of Americans who sought health information online reported that this influenced their communications with their doctors and their health decisions.2 With the ready availability of information, doctors can no longer anticipate that the patient will assume a passive role in her health. However, the power ultimately resides with the physician. Healthcare professionals are the only ones who can legally provide medical advice, and they are the ones who must write prescriptions. No matter how informed a patient, the decision to undergo a medical treatment or procedure is not hers alone.
Physicians do still have the power to suggest or reject a given procedure. Considering that many doctors own or have a stake in medical facilities or equipment, this leads to over-use of certain procedures. For example, a 2010 study found that when medical providers acquire MRI equipment, they tend to order more MRI scans.3 Similarly, when my physician was deciding whether to perform the procedure, he was likely aware of its profitability. Not only would he be able to bill for his services, but he also had a stake in the facility at which the procedure would be conducted. For about two hours of his time, he would gain a revenue of tens of thousands of dollars.
Many doctors are paid on a fee-for-service system, meaning that the more procedures they perform, the more they are paid. At the same time, however, performing an unnecessary procedure, especially a surgical one, has its own risks. Physicians in the US may face indemnity (compensation) payments averaging upwards of $250,000 per lost claim, even in low-risk specialties.4 This places a heavy burden on the medical provider, who must consider the effects on a variety of stakeholders while determining what is best for his patient.
Shared Decision Making, a Holistic Approach
Healthcare providers have developed a strategy for making decisions alongside patients, instead of for their patients. This is called shared decision making, and it is a core component of the patient-centered medical approach. While evidence-based medical practices utilize statistics and averages to determine the best course of action for a patient, patient-centered medical practices focus on each patient as an individual, assessing the given patient’s specific needs.
For example, if a patient presents with a certain condition, a doctor practicing evidence-based medicine might choose Medication A, which has been shown to be 95% effective, but must be taken at the same time every morning for a week. If that same patient visited a doctor utilizing a patient-centered approach, the doctor might ask questions about the patient’s lifestyle. If the physician finds that the patient will likely not be able to take the medication at the same time every day, the doctor might prescribe Medication B, which is 85% effective but only needs to be taken once. Though Medication B is less effective overall, it is more likely to be successful with the given patient. This approach requires the doctor to ask questions of the patient and learn what medication will best meet her needs, likely through shared decision making.
In shared decision making, both the patient and provider are equipped with all information about the options for a given medical concern, and work cooperatively to evaluate the most appropriate path.5 In this case, neither the physician nor the patient is able to make a completely appropriate decision on her own. This requires that the provider spend a significant amount of time with each patient, learning about the patient’s situation. Though time is a precious resource, the extra few minutes may be worth it. Shared decision making has been shown to increase patients’ knowledge, provide patients with more accurate risk perception, reduce patients’ internal conflict about medical decisions, and keep patients from remaining passive or undecided in their medical decisions.6 When patients and providers are able to spend time making an appropriate decision, patients generally see better outcomes.
“She was right,” my doctor, told my waiting family six months later as I lay in the recovery room. His voice was laced with surprise. He found and removed three endometrial lesions – two from my uterus, one from my ovary – as well as a puddle of liquid that had accumulated in my abdominal cavity. In this case, the patient was right, and the procedure was indicated. When my family told me of my doctor’s apparent shock, however, I was left to wonder why he would have cut me open, had he not been convinced of the diagnosis. This confusion prompted me to explore the context in which physicians work. Physicians should not simply make decisions for patients, but instead make decisions with patients. Patients know their bodies, and physicians know their medicine. Together, doctor and patient can ensure the best possible medical outcome.
1. Beisecker, AE. Patient power in doctor-patient communication: What do we know?. Health communication 1990;2(2).
2. Fox, S, Lee R, and Horrigan J. The Online Health Care Revolution: How the Web Helps Americans Take Better Care of Themselves. Washington, DC: Pew Internet & American Life Project; November 2000. PIP Health Report. 2006.
3. Baker, LC. “Acquisition of MRI equipment by doctors drives up imaging use and spending.” Health Affairs 2010;29(12).
4. Carroll, AE., and Buddenbaum JL. High and low-risk specialties experience with the US medical malpractice system. BMC health services research 2013;13(1).
5. Barry, MJ, and Edgman-Levitan S. Shared decision making—the pinnacle of patient-centered care. New England Journal of Medicine. 2012;366(9).
6. Stacey, D, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2010;10(10).