Sep 27th 2017

Patients Want a Say in Healthcare Decisions That Will Affect Their Lives

Only 20 or 30 years ago, patients were comfortable letting their doctor decide the medical treatment that was best suited for them. Today, not so much. Patients now want a say in the healthcare decisions that will affect their lives.

According to Dr. Howard Bauchner, editor-in-chief of the Journal of American Medical Association (JAMA), this is particularly true of end-of-life or chronic-care issues. "Around acute care, I still believe that most patients are comfortable with physicians making the decisions," says Bauchner on  The Scope at the University of Utah Health Sciences Radio

Bauchner says the trend towards patients wanting more say in chronic care options is especially evident in three specific areas: 

  • Women's decisions about what type of treatment they get for breast cancer
  • Men's selections on treatment for prostate cancer
  • Statin use, especially related to new recommendations

Bauchner points out that because only 20 or 25 percent of medical decisions can be made based on randomized controlled trials (RCTs), roughly three-quarters of the decisions that physicians make daily tend to be based solely on observational data. So patients should have the right, and in fact the obligation, to weigh in on those decisions alongside their physicians.

When the data doesn't clearly render a judgment, or when a patient has many options, discussions between a care provider or physician and their patient will be fundamental to reaching a reasonable medical decision.

Take women's breast cancer. Women are relying on evidence-based information from their physician in getting quality care, but they also hope that their personal choices, lifestyle preferences, and research support the treatment choice. While some patients want a lot of information, others may not. Yet within a single breast cancer diagnosis, for example, patients must make multiple choices per each stage of treatment, such as mastectomy vs. breast-conserving surgery with radiation; which chemotherapy drugs to use; and whether to have reconstructive surgery after mastectomy, at a later date, or not at all. And that's just one example of a patient's involvement in her treatment decisions. 

Likewise, end-of-life issues are a clear example of an area in which a patient wants to exercise more control and autonomy in their treatment decisions or lack thereof.

Achieving Cultural Competence in Medicine (CCM)

One way physicians have evolved from autocratic to collaborative is through the adoption of Cultural competence in medicine (CCM). CCM is the delivery of health services that acknowledges and understands cultural diversity in the clinical setting and respects individuals' health beliefs, values, and behaviors. CCM's origins sprung at least in part from a simplistic effort to teach doctors about the cultural norms and idiosyncrasies of certain population groups regarding healthcare and medical decision making.

More recently, CCM has evolved into a kind of narrative medicine, a philosophy that seeks to understand each patient's story and integrates what's important to them into their choices and decisions around healthcare, i.e., to improve health quality by individualizing healthcare rather than standardizing it.

From the patient's point of view, an early criticism of evidence-based medicine was that it robbed them of their personal choices in reaching an optimal healthcare decision. But in recent years, we've seen greater emphasis on patient inclusion—and CCM has been at the forefront of trying to preserve the practice of evidence-based medicine, when appropriate. For example, patients' preferences are now sometimes incorporated into the very first models of evidence- based medicine.

eviCore understands that while evidence-based medicine enables both physicians and their patients to make better-informed healthcare decisions, a more accommodating model— research-enhanced healthcare—is emerging, in which patients and their physicians can mutually arrive at the best healthcare choices while taking into account the patient's personal choices.