For most patients in the real world, getting good medical care involves complicated decisions. It’s not as simple as what often gets shown on TV, where a patient goes in, the doctor figures out what’s wrong, and then he performs some lifesaving surgery. Most of modern medicine, especially for the elderly, is a lot messier — usually there’s not “right” answer, no perfect treatment. And a patient needs to be an active participant in making choices in treatment. All too often, they don’t have that opportunity to do that, and it gives rises to a common — but unacknowledged — kind of medical mistake.
Take Maria H. (not her real name), a woman I met a couple of years ago. A slim, pretty woman who emigrated from Brazil when she was 18 to go to college, Maria was a wreck at 44. She could barely climb the stairs in her home without having to take a rest. Her heart was so damaged, she could not mop the kitchen floor, walk the dog or carry a bag of groceries. The cause of her problems? A botched heart procedure she had not needed in the first place.
Two years earlier Maria started having panic attacks. Her heart would race, she was short of breath, and her chest hurt. Tests in the emergency room showed her heart was perfectly fine. What she needed was some help in coping with an abusive husband and other stresses in her life. A cardiologist told her he wanted to do a catheterization, an imaging procedure, “just to be sure” that her symptoms weren’t caused by heart disease. Maria was scared. She didn’t understand that the catherization was entirely elective, that it wasn’t necessary and that the chances that she had heart disease were virtually nil.
She was also in the dark about the risks of the procedure. Her heart stopped during the catheterization, and now she really does have serious, debilitating heart disease.
What happened to Maria could be considered a medical mistake, but not the usual kind, in which the doctor makes the wrong incision in a procedure or worse — operates on the wrong patient. In Maria’s case, she got a surgery that she would not have wanted, had she understood all of her options and the risks of each. How often this kind of error occurs isn’t known — although studies suggest as many as half of some kinds of surgeries are done on patients who would have chosen a different treatment.
Fortunately, there’s a remedy for this kind of error. It’s called “shared decisionmaking,” and last week a major medical journal published a study of the real-world implementation of this method of making sure patients are involved in decisions about their own care. The study was published by researchers at Group Health Cooperative of Puget Sound, an integrated insurer and clinic in Washington state.
In the Group Health experiment, patients with arthritis pain of the knee and hip were offered a patient-decision aid, a brochure and video that explained their condition, went over the various ways that they could be treated and laid out in explicit and simple terms the potential risks and benefits of each treatment. Once patients had a chance to look at the video and brochure, they were then able to discuss with the doctor which treatment was right for them.
Here’s the astonishing part of this study. Over a year and a half, Group Health saw a drop in the rates of hip replacements by more than a quarter and knee replacement by almost 40%. That suggests that when patient-decision aids weren’t used and when doctors weren’t practicing shared decisionmaking, as many as 1 in 5 patients who got a knee replacement would have chosen a different treatment if they had been given the option.
We also might be able to save some money by doing the right thing for patients. Group Health saw a 12% to 21% savings among their patients with knee and hip arthritis. If the Group Health experience is representative nationally, there are over 200,000 patients getting unwanted joint replacements every year (200,000 is a low estimate based on 25% reduction in hip replacement on 800,000 replacements per year). No, this isn’t as bad as a doctor who, say, replaces the wrong hip. But it’s still a mistake, and both doctor and patient have a responsibility to prevent it.