What if some of the challenges besetting health care today, from bloated medical expenses to aggressive overtreatments that deliver meager improvements, could be resolved by encouraging patients to demand explanation for the tests and procedures their doctors order?
It is a plausible approach. Increased patient input during medical consultations would likely reduce unwarranted surgeries and associated costs and complications, according to new research published this month in the peer-reviewed journal Health Affairs. But the study makes an unsettling discovery: that even affluent and well-educated patients would rather not question the recommendations of their physicians.
The main reason? A fear of being labeled "difficult." Patients from three primary care practices in Palo Alto, Calif., an affluent suburb of San Francisco, who were interviewed for the study said they often perceived their physicians as "authoritarian" and preferred not to challenge their views so as not to displease or disappoint them. Some explained they were afraid that asking too many questions might cause the doctors to care less about their health and provide them with lesser-quality care in the future. Still others valued maintaining the good will of their physicians and felt that being too assertive might damage their long-term relationship.
"Patients should play a role because they live with the outcomes of care," said Dominick Frosch, PhD, the study's lead author and an investigator at the Palo Alto Medical Foundation Research Institute's department of health services research, in a telephone interview. "Informed patients often make better choices than uninformed patients, who receive care that they would not want if they were better informed. That has implications both for individual health outcomes and for our larger health care system in terms of costs."
Nevertheless, a 69-year-old woman found herself apologizing to her doctor for refusing recommended surgery, saying she hoped the doctor would not be mad at her. Another patient, an 86-year-old woman, told the researchers she felt guilty about taking up too much of the doctor's time, but later blamed herself for not demanding more information. And a 49-year-old man said he did not want to annoy his physician and "rock the boat" by challenging their authority.
Despite the fact that some respondents were aware physicians did not know everything about their symptoms and felt they had a right to share their concerns, their reactions as told to the researchers run counter to what patient advocates believe would help realign priorities in health care: increased patient collaboration.
The discrepancy exists largely because not all medical advice is based on evidence that a treatment improves health or quality of life, although it is widely assumed that medicine is always backed by science. Alternative treatments are often available, depending on patients' preferences, tolerance for risk, and degree of external or family suport. But compounding this are built-in financial incentives for doctors to deliver more, rather than better, care, as I wrote in a recent post about Dr. Otis Brawley's views on evidence-based medicine and profit-driven care.
Frosch acknowledges as much. "A lot of the care that is provided in the U.S. is still in the fee-for-service environment. The incentives are set up so that counseling is not well reimbursed," he said. By contrast, diagnostic and urgent care services generate significant profits for doctors, labs, specialists and hospitals.
"There is a lot of pressure to make decisions quickly so that you have something to bill," Frosch said.
In this context, patient participation in clinical consultations seems critical. Yet the researchers, who interviewed a total of 48 patients, found they would rather investigate medical issues and treatment options on their own than try to form genuine partnerships with their physicians.
"There is a lot of rhetorical support for patient-centered care and some effort under way, but there is still a lot to be done," Frosch said. He noted that while the study measured patients' perceptions of their interactions with physicians, rather than independently assessed patient-physician relationships, the answers reveal the most likely reasons that preclude patients from engaging in their own health care.
The study's results have implications for the emerging science of shared medical decision making and its effects on health care costs, patient satisfaction and health outcomes. According to the Agency for Healthcare Research and Quality, which together with the National Institutes of Health is leading an initiative to introduce shared decision making measures in 2013, a growing number of patients are no longer willing to let their treatments be selected for them. However, informed consent forms rarely take into account patient preferences, and patients are usually not told about the full range of clinical options and their risks and benefits, the agency has stated.
