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Physicians rarely give patients enough information

Surgeons actually did a slightly better job than primary care physicians of providing patients with thorough informed consent, a study indicates.

By Vida Foubister, amednews staff. Jan. 17, 2000.

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Physicians routinely fail to fully involve patients in their medical decisions, according to a study recently published in the Journal of the American Medical Association. Out of 3,552 clinical decisions made in 1,057 patient-physician encounters examined in the study, only 9.0% met the authors' criteria for informed decision-making. The office visits analyzed in the study were audiotaped in 1993 and involved 59 primary care physicians and 65 general and orthopedic surgeons practicing in Colorado and Oregon.

The authors found that patients were completely informed about basic decisions such as laboratory tests in 17.2%of the cases, while none were completely informed about intermediate decisions such as new medications and only one was completely informed about complex decisions such as prostate cancer screening -- procedures that often require patient consent.

"Even though there may be a signed consent form, when all is said and done the process that leads up to [consent] may be inadequate," said Clarence H. Braddock III, MD, MPH, the study's lead author and an assistant professor in the Dept. of Medicine at the University of Washington in Seattle.

Ultimately, this failure to involve patients in medical decision-making might adversely affect their care.

"Outcomes can be optimized by matching diagnosis strategies and treatment strategies to patients' preferences," wrote Michael J. Barry, MD, chief of the general medicine unit at Massachusetts General Hospital in Boston, who wrote an editorial accompanying the study. "There's less of that going on than [is] optimal."

Communication and compliance

Outcomes are improved by better communication, proponents argued, through improved compliance.

"If patients know what's happening, they're much more likely to follow through; and if they're involved in decision-making, they're much more likely to follow through," said Maysel Kemp White, PhD, associate director for the Bayer Institute for Health Care Communication in West Haven, Conn., which partially funded Dr. Braddock's study.

Though the office visits occurred in 1993 and physician-patient communication has recently been in the spotlight as an area that needs attention, experts said the low level of informed consent found in this study is still representative.

"There's still enormous room for improvement," said Rudolph M. Navari, MD, director of the Walther Cancer Research Center at the University of Notre Dame.

Doctors tend to think of informed consent in legal, rather than ethical, terms.

"They see it as something they're required to do by law, by their hospital policy, to protect themselves from potential legal liability rather than as a positive obligation, as a positive step to involve the patient and derive the benefits from that," Dr. Braddock said.

Some physicians -- particularly those in highly penetrated managed care markets -- blame their failure to obtain complete informed consent on inadequate time.

But not everyone agrees with that contention.

"Time is not a major barrier," Dr. Braddock said. "It doesn't take that much more time to say a few more words or to reformulate what you're saying in such a way that it's more effective and more in line with good, informed decision-making."

In one of the study's more surprising findings, surgeons actually fared slightly better than primary care physicians in terms of how completely they informed patients of treatment options and risks. "In general, surgeons did a better job of informed decision-making, even though their visits were, on average, three minutes shorter," Dr. Braddock said.

Communication a focus

Current efforts to improve communication include an Assn. of American Medical Colleges report on Communication in Medicine that came out in October 1999 as part of its Medical School Objectives Project.

"This is a critical area to have students exposed to and inculcate in them the necessary skills and knowledge," said M. Brownell Anderson, the AAMC's associate vice president for medical education.

Though Dr. Navari believes physicians need to communicate better, his current research on the doctor-patient relationship in cancer treatment is focusing on patients.

"My idea is [to] take the patients and their families right after their diagnosis, sit down with them, go through a pretty detailed educational process and teach them the right questions to ask," he said.

The Bayer Institute is one organization that currently offers CME programs for doctors, medical support staff and patients geared at improving communication.

"The strategy that we tend to teach throughout our courses is one of real mutual decision-making, of taking the time to educate the patient, tell them what's happening, explain the options and then partner with them on choosing the best option," Dr. White said.

For physicians, this might mean using pamphlets and videos to educate patients so they have more time to spend discussing their treatment options.

"It will require some rethinking of how we practice, but it's important," Dr. Braddock said.

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