I took a quick trip to Target a month ago and browsed for new jeans. I approached the clothing section and was suddenly struck by the overwhelming challenge I had undertaken. From rack to rack, I had to choose from a multitude of different brands (Levis, Wrangler, True Religion and more), different styles (skinny, bootcut, tapered and more) and different colors (blue, black, tan and more). I had to figure out my current exact size and, even then, there are many different ways to size jeans (small-medium-large, waist-by-length and others). Even if I had known my size and style, I had to decide how I would wear these new jeans and with what shirt, shoes and accessories I would pair with them. Once I decided on the right size, style and role, I realized that each pair touted each of their unique differences, such as “extra stretch” or “made from recycled material” or “extra long-lasting.” All that to say, I left empty-handed.
In the grand scheme of things, the choice of jeans matters little. Unless one is a fashion designer or a model, one’s career or self-worth is not necessarily tied up in this decision. A shopper can try on many different pairs in the store that day to find the right fit. Even many weeks after this decision, the buyer can easily reverse it with a quick exchange for a new pair. After all, one likely has already grappled with many more decisions that day, ranging from nearly inconsequential (choosing where to eat lunch or where to park the car) to almost existential (choosing which career to pursue or how to buy that first house).
Though the degree of importance differs with each of these decisions, the thought process behind them is the same. There is usually an overwhelming number of options to consider when making a decision. The challenges associated with these decisions bring about anxiety, unease and ultimately dissatisfaction in the chosen option. When selecting the best treatment option for a new medical diagnosis, the same principles apply.
The medical field of our grandparent’s generation was far different from the one we strive to enter today. Chief among these differences was the process by which treatment plans were selected. Generally, conversations would go as follows: “Mrs. Jones, it seems as though you have X diagnosis. I am proud to say we have the perfect (and only) treatment plan to offer you.” On rare occasions that multiple treatment options were available for a diagnosis, it was up to the physician to direct the best and most appropriate treatment plan. This was often dubbed the “Paternalistic” Era in medicine, a time in which it was up to the practitioner to figure out the diagnosis and treatment plan and for the patient to comply.
As archaic as this method may seem to us in the 21st century, there really was no other way this interaction could have occurred. There was no access to the internet, no ability for anyone to simply Google their diagnosis and watch how the treatment options compare on YouTube. If patients wanted to understand their options, they would have to browse the medical literature themselves, which was as dense, uninteresting and difficult to understand as it is now. This method of medical decision-making began to change in the 1950s with the rapid discovery and implementation of new medications and procedures. Over the next 70 years, the explosion in the number of new medications and procedures, along with the availability of easily digestible medical information on the internet, has allowed patients and providers to collaborate more.
In clinical offices all over America today, patients arrive knowing far more about their diagnosis and treatment options than ever before. They have already received their official diagnosis (with proper ICD-10 code) via their electronic medical record messaging service with information and resources for them to browse. They have already searched on WebMD.com or Mayoclinic.org and have printed out a list of available treatments. They have heard of their favorite celebrity trying this new drug or endorsing that new device or numerous blog posts cataloging hundreds of individual experiences with the same diagnosis. And with the recent boom of medical TV shows, from Scrubs to Grey’s Anatomy to House, patients are more interested in medicine and more medically literate than ever before.
Shared decision-making, in which a physician and patient work together (guided by the medical literature) to form a treatment plan, certainly has its benefits. For one, patients can make decisions regarding their treatment options that most closely align with their values. Each treatment decision comes with its benefits and downsides, allowing the individual to weigh their situation and choose the option that suits their own goals and lifestyle. As a patient, I would prefer a “let us discuss the various options you can select from” versus the “take these pills or you’re screwed, up to you” of the past. When a patient is an active participant in their decision, they are more likely to adhere to the treatment regimen and achieve better health outcomes. Another advantage of shared decision-making is the advancement of the physician-patient relationship. Physicians are allowed to prove to patients and the public the recently-challenged idea that they care for each individual they see and want what is best for each person. By offering all (FDA-approved) available options with objective data, the stigma of “being in the pockets of big-pharma“ cannot exist. No longer can physicians simply push expensive procedures; instead, patients have to desire the procedure themselves. Physicians receive less hate, and patients have more confidence in their providers: win-win.
But imagine developing a routine UTI. Over 100,000 E Coli grew in the urine culture and, luckily, they are pan-sensitive to all tested antibiotics. The provider reveals the culture results and, in the name of shared decision-making, proceeds to discuss the benefits and downsides of each antibiotic regimen. What should have been a quick “here is a three-day course of Macrobid, call if any issues,” turns into a labor-intensive journey of trying to choose between “Macrobid 100mg every 12 hours for three-to-seven days” versus “Bactrim 160mg every 12 hours for three-to-seven days” versus “Augmentin 875/125mg every 12 hours for three-to-seven days versus…” I would be happier just receiving the most appropriate antibiotics for my condition and having faith in that.
How about ovarian cancer. One may trust the regimen your gynecologic oncologist recommends and assume it is the most evidence-based treatment to help manage the new diagnosis. Or they may demand to be taught all of the benefits and risks of each specific chemotherapy regimen, read the compendium of literature themselves and come to a decision. How can anyone expect to become an expert on cancer therapeutics overnight and make decisions that will likely impact the rest of their life? Based on how bad the cancer is, they may not even have the time to do so. 65% of people without cancer say they would want the ability to choose their treatment option if they got cancer, but only 12% of people who were diagnosed with cancer wanted to choose their regimen.
More broadly, what about treatments that offer known different efficacies? In the surgical management for female stress urinary incontinence (SUI), one may choose between a mesh sling and a native-tissue repair (using one’s own body tissue as a sling rather than a mesh). They both treat SUI fairly well, but mesh treatment touts a 95% cure rate, while native-tissue repair can only tout a 70% success rate. Native tissue has a higher incidence of fistula formation, while mesh has an (minimal) chance of mesh erosion or allergic reaction. 95% versus 70% may seem like a no-brainer from an analytic perspective, but how do actual people interpret these results? We can frame the mesh vs. native-tissue repair in tons of different ways: “95% versus 70% success rate,” “5% versus 30% failure rate,” “100% vs. 0% chance for placement of a foreign body,” or “x% versus y% chance of some side effect.” With a slew of secondary outcomes, potential adverse effects and patient satisfaction scores, it can be almost impossible to truly understand the true cost-benefit analysis of each option. And this does not even begin to include the other options, from pelvic floor physical therapy to pessary fitting to expectant management, each with its efficacy rates, adverse effects and changes to overall quality of life.
Every patient is different. Some patients love to learn all they can about treatment options, mull them over and make a decision. They love to read blogs, articles and patient forums to understand others’ experiences with these treatments and have a strong sense of what they do and do not want. I have been personally amazed by the large number of women who adamantly do not want a pessary placement for their SUI. However, I find that most patients are scared, in pain or discomfort and looking to their provider to give them the confident best answer to improve their health. Why even see a practitioner if you can look up the available treatment options online and pick one out for yourself?
Patient-focused shared decision-making has been one of the most impactful breakthroughs in medicine over the last 70 years. It has afforded patients more autonomy over their healthcare, improved adherence to chosen treatment options and improved the provider-patient relationship. However, keep in mind that medical decision-making is a challenging and labor-intensive process, something it took you four years of medical school and three-plus years of residency to grasp fully. And even then, attendings are still “practicing” medicine to master risk-benefit ratios and the best ways to communicate treatment options to their patients objectively. Patients cannot be expected to master the nuanced literature and expected outcome rates on their own. Next time you prescribe a treatment option for your patient, let them have their first choice but do not be afraid to tell them what you would recommend truthfully.