Giving Patients a Larger Voice

That's why Fairfax physician Krist tries to help his patients reach their decisions. In the decade that William Forrester has been a patient of his, they have discussed the PSA test annually. Most years, Forrester, a retired journalist, declined the test. No matter which way he chose, he says, Krist helped him feel comfortable with his choice.

"This is a new kind of medicine for me, to be involved in the decision-making," Forrester says. Last year, when he reached age 70, the two agreed that there was no longer any reason to screen him for a cancer that often takes 20 years or more to produce symptoms.

Sidestepping Harm

Many family practice physicians use some form of shared decision-making, but most doctors have not gotten on board. Some think they can't afford to spend the time it takes -- time for which they are generally not reimbursed. Others worry that they will be sued if a patient declines a screening test, such as the PSA, and then develops cancer down the road.

Payers, on the other hand, including Medicare, are looking carefully at making decision aids more widely available, and possibly even requiring that doctors employ the collaborative process before they can be reimbursed for certain procedures. That's because patients are often less interested in undergoing invasive -- and expensive -- surgeries and procedures once they've been fully informed.

In a recent meta-analysis, or study of several studies, Annette O'Connor, a health services researcher at the University of Ottawa in Canada, reported that patients who had access to decision aids were 21 to 44 percent less likely to choose a surgical option for such conditions as excessive menstrual bleeding, back surgery and angina, the chest pain caused by a partially blocked coronary artery.

John Wennberg, the director emeritus of the Dartmouth Institute for Health Policy and Clinical Research and one of the founders of the movement, has also long argued that if shared decision-making were widely adopted, it could help improve the quality of care in the United States -- and probably bring down costs.

Studies have found that most patients overestimate the likely benefit of treatments and tests while downplaying their potential for harm. And their doctors routinely misunderstand what their patients value and what kinds of treatment they would want if they really understood the trade-offs.

"We don't think of this as a medical error," Wennberg says. "But operating on a patient who didn't really want a particular surgery may be as bad as operating on the wrong knee."

Wennberg and a handful of researchers around the world have been working to formalize methods to bridge the gaps in patients' understanding about everything from back surgery to drugs to cancer-screening tests such as the PSA. Sometimes, a fairly simple discussion with a doctor is enough to fully inform a patient.

For other patients, decision aids are needed, because doctors often can't spend the time to sift through competing options and they're not trained to help patients weigh their worries and hopes against the various odds for benefit or harm.

These aids include short videos, brochures, questionnaires and interactive computer programs, which patients may take home and go through at their own pace.

Once they more thoroughly understand the pros and cons of a proposed treatment or test, they can then discuss it with their doctor, a process that generally leaves them more satisfied with their care.