There are three traditional models of physician-patient decision-making. In rheumatology, patients overwhelmingly prefer a collaborative approach. In today's column, we review the decision-making process in the doctor's office.
At the risk of complicating something that you as a physician may take for granted, I am broaching the topic of medical decision-making which, when done right, can improve patient outcomes.
There are three traditional models of physician-patient dynamics: The paternalistic approach, which is the traditional model in which the physician articulates and implements what is best for the patient; the informative approach in which the physician provides the patient with relevant information (risks, benefits, alternative plans) and asks the ptient to select the best course; and, then there's shared decision-making which is often referred to as the deliberative or interpretive approach. The latter is more collaborative in which your interactions with the patient are aimed at supporting them in making sound decisions. This approach includes helping the patient select the treatment that is best suited for their condition and unique situation.
Having limited time for lengthy discussions, the contemporary healthcare model reifies the paternalistic model. In one study of rheumatologists, reported they typically give detailed information only about their preferred options and give very little information about alternatives. That same group also reported that their patients “very rarely” asked for other recommendations as there was very little collaborative decision-making (Lipstein et al., 2014).
In another study, physicians reported that they typically underestimate their patients’ desire for information and overestimate their desire to make medical decisions (Degner & Sloan, 1992).
Contrary to those findings, there is a lot of research to suggest that patients benefit from being involved in the decision-making process. For example, patients report lower satisfaction with healthcare they receive in settings characterized by paternalistic models. Notably they report equally low satisfaction in settings requiring full decision-making autonomy.
Collaborative decision-making is associated with health literacy and compliance. An involved patient is invested in understanding their disease and options for treatment. Dr. Atul Gawande sums up the Goldilocks middle ground as follows: “We want information and control, but we also want guidance” (Gawande, 2014, p. 201).
This collaborative decision-making model is especially useful rheumatology where the challenges of managing chronic illness make treatment decisions more complicated. In fact, a 2007 study of different patient populations found that rheumatology patients were second only to fertility patients in their aversion to paternalistic physician relationships and also in their preference for more collaboration with their treatment team (Deber et al., 2007).
Why is it so hard to find and use this middle ground?
A 2016 study of rheumatologists identified the following barriers to shared decision-making: Doctor barriers (paternalistic attitude), patient barriers (lack of knowledge, lack of awareness that they can be involved in the decision-making process), and then there are contextual barriers, such as too little time during the appointment to discuss all treatment options (Nota et al., 2016).
Despite the obstacles, physicians are responsible involving patients in the decision-making process. A 2015 rheumatology working group about shared decision-making outlined the following seven key steps towards shared decision-making (Toupin-April et al., 2015):
More than anything, though, the most important first step is patient education. In healthcare research, doctors overestimate the patient's understanding of their disease and treatment options. It’s worth five minutes in your office or, collect and collate dependable educational resources for the patient.
I know of no other use of five minutes that has the potential to yield such a high return.
Lipstein, E. A., Dodds, C. M., & Britto, M. T. (2014). Real life clinic visits do not match the ideals of shared decision making. The Journal of pediatrics, 165(1), 178-183.
Degner, L. F., & Sloan, J. A. (1992). Decision making during serious illness: what role do patients really want to play?. Journal of clinical epidemiology, 45(9), 941-950.
Gawande, A. (2014). Being mortal: Medicine and what matters in the end. Metropolitan Books.
Deber, R. B., Kraetschmer, N., Urowitz, S., & Sharpe, N. (2007). Do people want to be autonomous patients? Preferred roles in treatment decision‐making in several patient populations. Health Expectations, 10(3), 248-258.
Nota, I., Drossaert, C. H., Taal, E., & van de Laar, M. A. (2016). Arthritis patients’ motives for (not) wanting to be involved in medical decision-making and the factors that hinder or promote patient involvement. Clinical rheumatology, 35(5), 1225-1235.
Toupin-April, K., Barton, J., Fraenkel, L., Li, L., Grandpierre, V., Guillemin, F., ... & Petkovic, J. (2015). Development of a draft core set of domains for measuring shared decision making in osteoarthritis: an OMERACT working group on shared decision making. The Journal of rheumatology, 42(12), 2442-2447