Boston, MA – What if you wanted a box of cereal right now? You could probably walk, ride or drive to any number of big grocery stores, small specialty stores or even convenience stores. Once inside, you’d stare down a long aisle of options from Applejacks to Wheaties.
That’s the kind of choice we’re used to as consumers – the nearly endless ability to pick what’s right for us. To reject options for their color, texture, taste, nutritional quality… or toy inside.
In healthcare it’s very different.
I remember a colleague talking about the critical role of choice in better health. Healthcare is all about obligations and directives, he said. Do this; don’t do that. Fill this; take this; measure that. There’s a reason that the side of the medicine bottle says use as directed.
Choice is at the crux of the patient engagement debate because, as several studies have suggested, people who don’t make an active choice may not make a lasting commitment. That’s a context worth exploring. If we can get people more involved, give them more choices, help them be active decision-makers in their own care, can we change the outcome?
The answer is still unknown. But, a new study out this month’s JAMA starts to shed a little light on where we are today.
Floyd Fowler, Bethany Gerstein and Michael Barry interviewed 2,718 people to understand how patient centered medical decisions are today. They focused on three categories that cover 10 conditions:
- Medications for blood pressure, cholesterol and depression
- Screening for colon, breast and prostate cancers
- Surgery for knee replacement, hip replacement, lower-back and cataracts
Generally, they found that discussions about surgeries tended to include more choices and a better of a balance of pros and cons than conversations about medicines or screenings. Doctors asked most patients (60 – 80%) for their input about medical decisions except in three key categories: hypertension, cholesterol and mammograms.
Only 37% of people diagnosed with hypertension were asked for input on their treatment. Many didn’t even know there were choices in prescriptions.
The most patient-involved decision-making was in knee and back surgeries where patients were both given options (86%, 90%) and asked for input into their final care plan (72%, 78%).
The investigators conclusion was that discussions about common tests and medications do not reflect a high level of shared decision making, particularly for five decisions most often made in primary care.
The truth is we have a choice in almost every aspect of our health. A choice to do better, to ask another question, sure. But also in what kind of care to accept or demand.
I think of a very brave woman in my life who has been battling Crohn’s disease for decades. It’s a terribly painful immune deficiency that’s impacted her life and work. Relatively early on in treatment, her doctor recommended a colostomy. It was complete and effective, for sure. But not the way she wanted to live every day. She told him: Find another plan.
Or, a young man, an avid runner, who we heard speak recently. He had tingling and numbness in his arms and legs. He went to his doctor, who told him he was just tired and not to worry about it.
Then he lost all feeling in his entire body. He immediately went to a different doctor who said he believed he had MS. He sent him to a hospital an hour away and ordered a MRI and spinal tap. The doctor told him that his suspicions were confirmed.
Choice is more powerful in healthcare than we know. Maybe we should have a few more doses of it?
See also: This powerful study about how a better understanding of what to expect from treatment changed people’s – including doctor’s – minds.
Posted by: Leigh Householder