Saving Healthcare Dollars: Doctor-Patient Talks, Not Forms, Should Guide Medical Decisions
Researchers at nine medical centers are trying to make "informed consent" forms more personalized and user-friendly, in hopes of helping patients better understand the risks of upcoming medical procedures and consider alternatives. While the approach has promise, it's unlikely it will be able to substitute for shared decision making between doctors and patients, which experts have long championed as a way to improve healthcare quality and reduce costs.
Known as Patient Refined Expectations for Deciding Invasive Cardiac Treatments, or PREDICT, the informed consent approach being tested at such centers as the Mayo Clinic and the Henry Ford Health System uses a Web-based program to educate patients who are preparing for non-emergent cardiac catheterization and potential angioplasty. Factoring in a patient's age, comorbodities, and other characteristics, the program draws on a national cardiovascular database to predict an individual's chances of death, internal bleeding, or renewed blockages of arteries. The probabilities are displayed in an easy-to-understand chart.
This is a radical departure from the usual process of what I call "uninformed consent," in which people facing a serious procedure are asked to read pages and pages of dense legalese and add their John Hancock. Even many well-educated people skip over this incomprehensible morass and sign the document, which is mainly designed to protect providers from being sued. Overall, 60 to 70 percent of patients do not read informed-consent forms.
The PREDICT philosophy, in contrast, is that patients should know as much as possible about the potential outcomes of a procedure before they undergo it. One Yale researcher, Harlan Krumholz, has even suggested that the personalized informed consent forms should contain additional information to help guide patients' decisions. The form might tell them, for instance, whether they'd do better or worse if they took medications instead of having the procedure, or it might reveal how many operations of this kind the patient's surgeon has performed.
It's a great idea, but don't hold your breath. Nearly 20 years ago, John Wennberg and his crew of researchers at Dartmouth Medical School took on the establishment by suggesting that physicians should provide patients with all relevant treatment alternatives and let them decide what they wanted. What a concept! Yet "shared medical decision making," as this approach is known, has yet to be widely adopted.
Perhaps that's because, at least where elective procedures are concerned, shared decision making has been shown to save money. Rather than have their prostates removed, and run the risk of incontinence and impotence, some men with benign swelling of the prostate have elected to take medications or live with frequent urination. Some breast cancer patients, when presented with the evidence, have elected to get lumpectomies rather than have their breasts removed. When people make such decisions, surgeons earn less.
Of course, physicians' considerations are not always that crass. Some doctors are frankly convinced that it's better to do a hysterectomy when a woman has heavy vaginal bleeding. And some doctors feel they're too busy to fully lay out the alternatives to patients. But whatever the motivation, their explanations are often less than complete. And that leaves us trying to come up with a better technological solution to uninformed consent.
Image supplied courtesy of Salim Fadhley at Flickr.