Agreement may boost disease management

Patient-physician collaboration may be key to controlling chronic medical conditions, but achieving it is often a challenge.

By Victoria Stagg Elliott, amednews staff. Dec. 8, 2003.

When patients and physicians concur on diabetes treatment goals and how to achieve them, self-management of the disease is improved, according to a study in the November Journal of General Internal Medicine.

The problem: Such harmony is elusive.

Agreeable treatment
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"Doctors are used to telling patients what they should do, often without giving very much information or being aware of the obstacles patients may face," said Michele Heisler, MD, the study's lead author and a lecturer in the Dept. of Internal Medicine at the University of Michigan Medical School, Ann Arbor.

But patient factors are key pieces of the puzzle.

"Patient goals are fundamental to primary care, although it's not a standard part of primary care to illicit what those goals are," Dr. Heisler said. "We have a higher percentage of our patients with long-term chronic diseases that require multiple complex behaviors. We're going to have to be better behavioral psychologists."

To explore issues related to this aspect of physician-patient communication, Dr. Heisler and others at the University and the Ann Arbor-based Veterans Affairs Center for Practice Management and Outcomes Research sent surveys to more than 100 diabetic patients and their primary care physicians.

5% of diabetic patients agreed with their physicians on 3 main treatment goals.

The results indicated that patient and physician agreement -- though somewhat rare -- was associated with improved condition management.

Patients wanted to get off medications and avoid insulin. Physicians wanted their patients to lower their cholesterol and blood pressure levels.

Only 5% of patients agreed with their physicians on three main treatment goals, and 13% didn't buy into their physicians' treatment strategies, although 40% of pairs overlapped on at least one goal, and 56% could agree on one treatment modality.

"Most research suggests that only about one-third of patients follow their doctors' treatment recommendations on a regular basis," Dr. Heisler said. "To improve these numbers and clinical outcomes, it is critically important that doctors work with patients to develop a workable treatment plan."

Valuing the patient's contribution

The authors and other patient-physician communication experts said this study indicates the need for cooperation to more successfully address any chronic disease -- not just diabetes -- that requires a lot of self-management.

"The more patients see that their contribution to care is important and what they believe has value, the better the outcome of diabetes, hypertension, congestive heart failure, headache," said Forrest Lang, MD, professor of family medicine at East Tennessee State University in Johnson City. "If they don't like the recommendations, they won't comply -- which is frustrating for everybody."

56% of diabetic patients agreed with their physicians on 1 treatment goal.

But experts also concede that there are numerous barriers to shifting from a system in which physicians tell a patient what's good for them to one where patients and physicians reach a conclusion with which they both can live.

"The position of patient goals in the practice of medicine is extremely low," said Nathaniel Clark, MD, RD, national vice president for clinical affairs at the American Diabetes Assn. "Doctors have to understand if their patients are not doing well, a portion of that may well be due to the fact that there is a mismatch in understanding."

Doctors and their patients might not even speak the same language. Physicians who all have graduate-level education in the sciences might have a very different perspective from their patients, who usually don't.

"Saying, 'I'm very concerned about your hypertension and if we don't treat this you might have an MI or a CVA' is very different than saying, 'I'm very concerned about your blood pressure because you might have a heart attack or a stroke,' " Dr. Clark said.

But even if doctor and patient fully understand each other, collaboration might take time -- a resource always in short supply. And sometimes, patients still might not feel a rapport that lets them share with physicians that they are thinking differently.

There is also the question, "What's best?" Should physicians struggle to convince patients of what's good for them, or is a merging of the minds a healthy choice? Should the patient's preferences hold sway? For example, should patients be counseled in such a way that they are more willing to go on insulin, if necessary, or should physicians work harder to help them avoid it because that's of primary importance to the patient?

One-third of patients follow doctors' treatment recommendations regularly.

"I don't think either group is right," Dr. Clark said. "The answer is that one needs to understand better what motivates patients. There's a terrible fear of insulin that has come from the way physicians have presented it." In these cases, the best course is to find an alternate approach.

Sometimes a physician's focus on the patient's reality also can make a difference.

"It's better to agree on an achievable plan that's OK than to impose an optimal plan that won't be carried out," said Robert B. Mellins, MD, professor of pediatrics at Columbia University College of Physicians and Surgeons, New York. He has written about using treatment plans to improve asthma management. "The problem is that people don't like to say no to doctors. It's very important when you get all finished to look at the patient and say, 'Can you live with this?' If there's a hesitation, you better back off and find out what the hang-up is."

Without patient agreement, study critics acknowledge, patient compliance would not be possible. But they also point out that, although agreement is a worthwhile goal, it's an uphill battle. Sometimes patients and doctors may have to agree to disagree.

"The trend towards better and earlier diabetes control means that patients should get on insulin earlier, but a lot of patients don't want to take insulin shots," said Katherine Martin, DO, a family physician in Harrisonburg, Va. "Right there, we're at odds."

ADDITIONAL INFORMATION:

Agreeable treatment

Objective: To assess the degree to which patients with type 2 diabetes agree with their primary care physicians on treatment goals and strategies and determine if agreement is associated with better disease management.

Method: 127 pairs of patients and their primary care physicians were surveyed about their treatment strategies and most important goals. Researchers then examined whether greater agreement was associated with better self-management.

Results: Only 5% of patients agreed completely with their physicians' goals, and 40% agreed on one goal. Fifteen percent didn't agree at all with their physicians' targets. At least 13% agreed on strategy, although 56% agreed on one strategy. Patients with more education and greater belief in the efficacy of treatment and who shared in the decision-making were more likely to agree with their physicians. Patients who agreed with their physicians were more likely to rate their diabetes self-management as good.

Conclusion: Patients and their physicians often did not agree on treatment goals and the means to achieve them, but agreement was associated with better outcomes.

Source: Journal of General Internal Medicine, November