April 2000 Bulletin

Meaningful dialogue is good medicine

A meaningful dialogue between physicians and patients is often a missing component in helping patients make clinical decisions.

So says Clarence H. Braddock III, MD, MPH, co-author of a study, "Informed Decision Making in Outpatient Practice, Time to Get Back to Basics," published in JAMA, December 22, 1999. The study concluded that informed decision-making among primary care physicians and surgeons "was often incomplete," and there was a "need for efforts to encourage informed decision making in the clinical practice."

"What’s needed is a dialogue, instead of an unidirectional, dutiful disclosure of alternatives, risks and benefits by the physician," says Dr. Braddock. "One reason has to do with just the ethical principle or virtue of being a good physician and showing respect for the patient. The patient also has a legal right to have a say-so in what happens to their body. And, at the same time, the physician’s role is not to usurp that right, but to act in a way to support that right by giving the patient your medical opinion and other information that helps the patient be an informed participant in the decision-making process.

"The other reason has to do with potential good consequences that flow with having patients involved in health care decisions. There is growing data that shows that when patients are allowed to participate in health care decisions, they are more likely to follow-through with medical recommendations such as compliance with medications or some other regiments. This can lead to better outcomes, as growing data shows these examples in diabetes care and treatment of high blood pressure."

The study analyzed 1,057 audiotaped encounters containing 3,552 clinical decisions among 59 primary care physicians (general internists and family practitioners) and 65 general and orthopaedic surgeons; two to 12 patients were recruited from each physician’s community-based private office.

"In general, the study found that surgeons may do a slightly better job at this [informed decision-making] because they’re most accustomed to having discussions about decision-making," says Dr. Braddock.

So how can physicians involve patients in the decision-making role?

"On the information side, physicians should think of ways to provide patients with written materials about their medical problem, including videos, web sites or the use of other health care professionals such as nurses or others," says Dr. Braddock.

On the decision-making side, Dr. Braddock says physicians "need to have a useable framework and perhaps some training in how to go about this more effectively" such as booklets or attending workshops where they can learn skills in more effective decision-making. "Then, the physician can spend the time in making sure patients understand the essence of decisions, walking through their own thinking about their recommendations and responding to questions and or other things," he says.

After going through this process, with both the patient and physician reaching a joint decision, Dr. Braddock says, "both the physician and patient will feel a sense of collaboration and ownership" of this decision.


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