On a Friday evening a few months ago, my mom broke her arm. A doctor in the E.R. told her it was a simple fracture, and put her arm in a sling. The following Monday, though, she called me. She had consulted two surgeons who had a different assessment: the bone was broken in four places, surgery would be quite involved, and the rates of complications were high.
“How high?” I asked.
“Twenty-to-fifty-per-cent risk of avascular necrosis,” she said.
“And the alternative?”
“No surgery,” she said. “Good chance of immobility and arthritis for the rest of my life.”
And then, after a moment of thinking I might throw up, I said, “I don’t understand. What does avascular necrosis mean?”
Here’s the thing: I’m a doctor. Strictly speaking, I know what avascular necrosis means. It means the bone can die. It means the blood vessels can be compromised. Which means, again, dead bone. My mom, a cardiologist, knows this too, as does my father, a rheumatologist.
But what I meant was: What did it really mean? How would it feel? How was she supposed to make such an impossible decision?
According to the Affordable Care Act, one answer is something called “shared decision-making,” or S.D.M. It’s an approach to medical care in which patients are encouraged to make decisions with their doctors. For some clinical scenarios, like having a heart attack, there is one best treatment, but for many others more than one reasonable option exists. For these less clear-cut decisions, like treatment of early-stage breast cancer, or whether to get prostate-cancer screening, S.D.M. aims to integrate patients’ preferences and values into the weighing of each choice.
Though S.D.M. has captured the attention of policy leaders, investors, and researchers over the years—leading to the creation and testing of support tools, known as “decision aids”—it is rarely used in clinical practice. The A.C.A. aims to change that; it requires Accountable Care Organizations to integrate S.D.M. into the daily rhythms of patient care. Patient-satisfaction surveys, which are being used to partially determine reimbursement, will ask patients whether or not their care honored the principles of S.D.M.
S.D.M. advocates have argued that heeding patient preferences will help improve quality and cut costs. That remains to be determined. For now, we can at least agree that physicians can never fully grasp, nor anticipate, the subjective nature of their patients’ experiences. But whether the answer lies in asking patients to share more in the decision-making process remains a matter for debate. Doctors know all about probabilities and trade-offs, but we don’t know much about how to engage patients in decision-making in a way that actually achieves the most desired long-term outcome.(...)
So we increasingly ask our patients: Which do you prefer?
Do you want chemo and three months of life, or six weeks of life without the nausea and vomiting that the chemo causes? Do you want high-risk open-heart surgery, with a fifteen-per-cent risk of dying during the operation, or would you rather continue as you are, with a fifty-per-cent chance you will be dead in two years? Do you want a prostatectomy, which has a five-per-cent chance of impotence and incontinence, or radiation, with a three-per-cent chance of leaving a hole in your rectum, or would you rather “watch and wait,” with the chance that your cancer will never grow at all?
Image: Garo/Phanie/Science Source.
“How high?” I asked.“Twenty-to-fifty-per-cent risk of avascular necrosis,” she said.
“And the alternative?”
“No surgery,” she said. “Good chance of immobility and arthritis for the rest of my life.”
And then, after a moment of thinking I might throw up, I said, “I don’t understand. What does avascular necrosis mean?”
Here’s the thing: I’m a doctor. Strictly speaking, I know what avascular necrosis means. It means the bone can die. It means the blood vessels can be compromised. Which means, again, dead bone. My mom, a cardiologist, knows this too, as does my father, a rheumatologist.
But what I meant was: What did it really mean? How would it feel? How was she supposed to make such an impossible decision?
According to the Affordable Care Act, one answer is something called “shared decision-making,” or S.D.M. It’s an approach to medical care in which patients are encouraged to make decisions with their doctors. For some clinical scenarios, like having a heart attack, there is one best treatment, but for many others more than one reasonable option exists. For these less clear-cut decisions, like treatment of early-stage breast cancer, or whether to get prostate-cancer screening, S.D.M. aims to integrate patients’ preferences and values into the weighing of each choice.
Though S.D.M. has captured the attention of policy leaders, investors, and researchers over the years—leading to the creation and testing of support tools, known as “decision aids”—it is rarely used in clinical practice. The A.C.A. aims to change that; it requires Accountable Care Organizations to integrate S.D.M. into the daily rhythms of patient care. Patient-satisfaction surveys, which are being used to partially determine reimbursement, will ask patients whether or not their care honored the principles of S.D.M.
S.D.M. advocates have argued that heeding patient preferences will help improve quality and cut costs. That remains to be determined. For now, we can at least agree that physicians can never fully grasp, nor anticipate, the subjective nature of their patients’ experiences. But whether the answer lies in asking patients to share more in the decision-making process remains a matter for debate. Doctors know all about probabilities and trade-offs, but we don’t know much about how to engage patients in decision-making in a way that actually achieves the most desired long-term outcome.(...)
So we increasingly ask our patients: Which do you prefer?
Do you want chemo and three months of life, or six weeks of life without the nausea and vomiting that the chemo causes? Do you want high-risk open-heart surgery, with a fifteen-per-cent risk of dying during the operation, or would you rather continue as you are, with a fifty-per-cent chance you will be dead in two years? Do you want a prostatectomy, which has a five-per-cent chance of impotence and incontinence, or radiation, with a three-per-cent chance of leaving a hole in your rectum, or would you rather “watch and wait,” with the chance that your cancer will never grow at all?
by Lisa Rosenbaum, New Yorker | Read more:
