Complex health choices require shared decisions
I recently saw a middle-age man in my primary care clinic who asked whether he should continue his cholesterol medication. He was reacting to new Food and Drug Administration warnings on statins, a class of drugs taken by more than 20 million Americans to lower their cholesterol. Though generally safe, statins can slightly increase the risk of diabetes, as well as mild, reversible memory loss, according to the new warnings.
My patient and I discussed several scenarios, trying to balance these risks against the drug’s benefit of preventing heart attacks. Should he discontinue his statin? Lower the dose? Or change to a less potent drug within the same class? With no obvious answer, I finally asked my patient, “What do you think?” It’s a question more doctors need to ask.
Involving patient input in medical decisions is a concept known as shared decision-making. According to the Institute of Medicine, it is a foundation of patientcentered care, where care is “responsive to individual patient preferences, needs and values.”
Options sometimes limited
Of course, some cases have only one acceptable option: vaccinating children, or surgery for an acute case of appendicitis, for instance. But in the majority of cases, the correct treatment is much less clear. Issues such as cancer screening, end-of-life decisions and whether to pursue elective surgery all have multiple feasible paths. That’s where shared medical decision-making plays a valuable role.
My patient, for instance, didn’t have a history of heart disease, which weakens the case for statin drugs. Cardiologist Eric Topol of the Scripps Clinic in San Diego says the reduction of heart attacks in patients like mine was 1 in 50, while 1 in 200 patients would get diabetes because of the drug.
So should a patient try to prevent heart attacks at all costs, and accept the drug’s side effects? Or is the risk of diabetes too great? The answer will vary, based on the preferences and values of individual patients.
Benefits are many
The benefits of engaging patients are significant. A 2011 Cochrane review, which analyzes the results of medical research, looked at 86 studies that examined patients who used decision aids — such as pamphlets, videos or Web-based tools — to help them make medical decisions. When these tools were used, patients reported an improved knowledge of their options, held more accurate expectations of harms and benefits, and reached choices consistent with their personal values.
But doctors often take a paternalistic approach to care, simply making the decision they think is best. Consider prostate cancer screening, where updated guidelines from the U.S. Preventive Services Task Force have made the decision of whether to pursue testing less certain. The estimated benefit of finding early prostate cancer has been reduced in recent studies, and further diluted by the harms that stem from prostate cancer treatment, which include impotence and urinary incontinence. Despite the complexity of that decision, a 2009 study in the Archives of Internal Medicine reported that barely half of patients recalled being asked for their screening preferences.
Back to my patient. After carefully considering his options, he decided to stop taking the statins. But had he decided otherwise, I would have respected his informed choice and continued the medication. The voice of patients needs to be considered for most medical decisions. That way, no matter what choice is made, it will always be the right one.