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Doctors ignore patients’ views on treatment

Well informed patients often choose less treatment than doctors expect

Louise Prime

Friday, 09 November 2012

Doctors frequently misinterpret or ignore patients’ preferences over their treatments, researchers from the US and Wales have found. They said patients often rate the ‘trade-offs’ of treatment as being much more important in their decision making than their doctors expect.

Their analysis, which appears today on bmj.com, looked at published research into the gaps between patients’ views on treatment and doctors’ perceptions of patients’ priorities. They assert that ‘preference misdiagnosis’ is a common problem that is damaging patients as well as increasing healthcare costs.

One study showed that only 7% of people with breast cancer rated keeping their breast as their top priority – but doctors thought that almost three-quarters (71%) of patients would rate it as the most important factor in deciding on treatment. And although doctors thought that living as long as possible would be the top priority for 96% of breast cancer patients considering chemotherapy, in fact the figure was only 59%.

Another study found that doctors placed far higher value than dementia patients on the continuation of life with severely declining cognitive function.

The authors found evidence that after patients are properly informed about the risks and benefits of treatments, they often make different decisions about treatment. For example, after men were told about the risks of sexual dysfunction after surgery for benign prostate disease, 40% fewer said they preferred surgery.

The researchers say there is much more to correctly diagnosing a patient’s preferences than simply asking patients what they want. First, they explain, the doctor needs to break the patient’s expectation of being told what to do, and instead engage in ‘team talk’, combining the doctor’s medical expertise with the patients’ expertise on their own priorities.

They should explain the risks, benefits and potential side-effects of each treatment option, and take patients’ verbal and non-verbal cues to help them ‘diagnose’ the patient’s preference. Some patients will then be confident enough to make their own decision regarding treatment.

If a patient asks the doctor to recommend which course to take, and the doctor is confident that their diagnosis of the patient’s preference is correct, they should confirm their understanding of the patient’s priorities for different health outcomes and then offer a recommendation. But if not, they should dig deeper to gain more understanding of the patient’s priorities.

The authors point out that this approach is not only ethically right, but could also cut healthcare costs. They conclude: “Evidence from trials shows that engaged patients consume less healthcare. More work is needed to understand the magnitude of this potential benefit, but it is tantalising to consider that budget challenged health systems around the world could simultaneously give patients what they want and cut costs.”

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