The importance of patient preferences in treatment decisions—challenges for doctors
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7414.542 (Published 04 September 2003) Cite this as: BMJ 2003;327:542All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
The long term time savings mentioned in the review by Say and Thompson pre-suppose a strictly personal list system of care. If the patient sees only one doctor, then communciation tasks achieved effectively (e.g. information sharing) might be supposed to benefit the time budget of subsequent consultations.
I am not aware of any research that has addressed the question of whether there is direct evidence for (or against) this assumption.
Let us allow that it is a reasonable assumption. Let us further consider the much more usual case of multiple doctors being involved in the patient's care. The costs (increased consultation time) are bourne by Dr Patient Centred and the benefits (less consultation time) are accrued by Drs Rushit and Busy who see the patient subsequently for the same problem.
Furthermore, Dr Patient Centred gets the reputation for being inclined to give this service, so even the patients of Dr Rushit and Busy come to him (or her) for a one off consultation when they want a good explanation and a chance for involvement.
In this system of care, everyone has a vested interest in perfoming poorly in this area of skill. Drs Rushit and Busy are profiting nicely and Dr Patient Centred experiences an insidious pressure to allow his (or her) performance to decline - and certainly little incentive to improve.
Competing interests: Professional Communication Skills Trainer
Competing interests: No competing interests
We refer to Say & Thomson’s article “The importance of patient preferences in treatment decisions”.(6 September)
It is a well researched and argued discussion and we agree broadly with its conclusions. As a group of experienced GP trainers we have long taught and encouraged the patients’ involvement in treatment decisions and note that this concept is enshrined in the merit criteria for evaluation of consulting skills for the MRCGP examination.
However it is disingenuous to have a debate about preferences without acknowledgement of the effect of health rationing decisions on choice. Too often we are aware that the true range of choices available to patients in well-resourced countries (let alone in developing health systems) is determined principally by problems of access to services. It is a hard task for a GP to discuss all treatment options with a patient, without excluding options that are not, in fact, available for reasons of health economics. How far should the discussion with the patient extend to explanations about allocation of resources?
Competing interests: None declared
Competing interests: No competing interests
Say and Thomson [1] suggest that, because of the possibility of biasing a patient towards a particular decision, a doctor "may need to determine how to present risk in a way that is helpful for an individual patient, or at least be able to present it in different ways". The point is well made, but there is a paradox.
Large volumes of information can paralyse the decision process and lead to poorer decision making. Put more simply, more is not necessarily better [2]. While experts (doctors) and non-experts (patients) alike have difficulty in integrating information [3], at least one characteristic of increasing expertise is an increasing ability to integrate complex information. So it might well be that a patient, presented with otherwise overwhelming amounts of information on risk, dangers, and benefits of a procedure, could reduce the difficulty of their decision task by asking just one question - “What would you do in my position?”
[1] Say RE, Thomson R. The importance of patient preferences in treatment decisions - challenges for doctors. BMJ 2003;327:542-545.
[2] Tversky, A, Kahneman, D. Judgment under uncertainty: heuristics and biases. Science. 1974 Sep ;185(4157):1124-1131.
[3] Hogarth RM. Process tracing in clinical judgment. Behav Sci. 1974 Sep;19(5):298-313.
Competing interests: None declared
Competing interests: No competing interests
In a recent article on the BMJ (1), Rebecca Say and Richard Thompson describe some crucial problems that health professionals encounter when confronted with patients' personal points of view about treatment. In particular, they point out the lack of time and communication skills of most doctors.
In fact, "patient's time” is often different from "doctor's time", in that the first is usually influenced by emotions and previous experience or knowledge, while the second is increasingly limited by institutional, economic and bureaucratic restraints. In addition, many doctors are not fully aware of the changing attitude of most patients towards their health. We all live in a world deeply influenced by media and market rules, where patients/consumers are incited by inexorable "information pressure" about health, disease and new promising treatments.
Moreover, health information, that is partly controlled by pharmaceutical companies, frequently produces apprehension and arouses new expectations among "health consumers", rather than reassuring them. In such a context, informing patients is not enough. Indeed, rather than talking, doctors should learn to listen to their patients, in order to recognize their personal views and opinions about disease and treatment. In this way, Therapeutic Patient Education (TPE), a distinct branch of health education aimed at patient empowerment, could represent a practical solution.
Indeed, by TPE, doctors can help patients and their families to understand disease and treatment, enabling them to be more actively involved in decision making. Moreover, since TPE involves the regular evaluation of results, it also provides measurable clinical outcomes. Unfortunately, most health professionals still ignore this powerful resource and fail to distinguish between education and information. Indeed, while patient information is frequently a one-way, doctor-centred action, TPE is an interactive, patient-centred process. In addition, by promoting the "holistic" vision of the patient, TPE overcomes the technical and sometimes reductive perspective of many doctors when dealing with patients' opinions and needs. In turn, this change of perspective promotes doctors' humanity and proficiency. However, to put into practice effective TPE, health professionals must learn specific skills and open themselves to both inter-disciplinal and inter-professional teamwork (2).
We think that, changing the attitude of health professionals toward their patients, TPE can make of patients’ requests and preferences an opportunity rather then a challenge. In conclusion, promoting the empowerment of both doctors and patients, TPE represents the only true challenge for all.
1. Say R E, Thomson R. The importance of patient preferences in treatment decisions-challenges for doctors. BMJ, 2003; 327:542-5.
2. W.H.O. working group. World Health Organization, Regional Office for Europe. Therapeutic patient education. Continuing education programmes for healthcare providers in the field of prevention of chronic diseases., Geneva, 1998.
Competing interests: None declared
Competing interests: No competing interests
Editor- We were interested to read Say and Thomson paper on the importance of patient preferences in treatment decisions, which is long overdue in major medical journals 1. Unfortunately, we were disappointed to note that there was no record of the role of patient doctor partnership concerning children in their otherwise excellent paper. Since one fifth of the UK population are under 16 years of age this is an important omission.
Traditionally health professionals involve parents in making decisions for care of children. All the points raised in the article are valid in this professional-parent relationship. In addition, professionals should satisfy that decisions are made with the best interest of the child. When there is a dispute regarding the best interest of the child either parents or the professionals could seek legal redress. The health professionals are increasingly encouraged to listen to children and to respect their opinion. The relationship of health care professional with the parents and the child changes as the child matures. The issue of Gillick competence when taking a child and their parents over a period of years is one of the most challenging areas of modern paediatrics. It can understandably be thwart with serious difficulties and any health care professional walks a dangerous path if they practice with it being unrecognised. Say and Thomson otherwise excellent paper was deficient in exploring this avenue, which clearly merits an article by it self as there is wealth of literature on the subject.
1. Say ER, Thomson R. The importance of patient preferences in treatment decisions-challenges for doctors. BMJ 2003;327:542-545
Competing interests: None declared
Competing interests: No competing interests
Dear Editor,
We congratulate the authors for a well written article highlighting a major problem in healthcare.
It would have been helpful to know the time period of the search performed by the authors as we recently published a paper titled "The patient's dilemma: prostate cancer treatment choices" (Patel HR et al, J Urol. 2003 Mar;169(3):828-33). Our systematic review covered the standard articles but also took into account the mass of information available via the media, internet etc.
From our study of prostate cancer treatment choices, when there is poor quality evidence or little professional consensus to support a particular treatment over another, no clinical guidelines regarding treatment are possible. Patients are faced with a series of options, and the data reveal that the process of choosing between these options is based on input from a large number of sources. These sources differ in the way that benefits of treatment are emphasized over harms and vice versa. We identified little evidence regarding which type of input exerts the greatest influence on patients. It may be that the sources associated with the most bias have the greatest influence.
We concluded that there is a paucity of information on how patients with prostate cancer use different types of input in the treatment decision making process. The physician, as principal caregiver, still appears to have the most direct influence on patient choice. Just how long this status will continue is uncertain.
Competing interests: None declared
Competing interests: No competing interests
As pointed out by Rebecca Say and Richard Thomson [1], some doctors may wish to retain the imbalance of power between themselves and their patients.
This might be an understatement. In my view, this kind of wish can even be the mean reason why some students chose to become medical doctors.
[1] Say RE, Thomson R. The importance of patient preferences in treatment decisions—challenges for doctors. BMJ 2003;327:542-545.
Competing interests: None declared
Competing interests: No competing interests
Information as an end
Editor - Say and Thomson have produced an interesting article but the most striking feature of their case presentations is the desire for more information among their patients[1] . These needs can be underestimated by clinicians[2] but disease information is often more important to patients than discussion of treatment[3]. Indeed while there is little evidence that patients benefit from making decisions, the benefits and necessity of keeping them informed are widely recognised[4,5].
It may be that involving patients in decisions will help them to learn more about their illness but there is also a danger that by focusing on decisions we become distracted from an area of real importance, where deficiencies still exist[6]. Perhaps it is therefore more useful to regard information as an end in itself, rather than as a means to an end.
[1] Say RE, Thomson R. The importance of patient preferences in treatment decisions - challenges for doctors. BMJ 2003; 327: 542-545.
[2] Strull WM, Lo B, Charles G. Do patients want to participate in medical decision making? JAMA 1984; 252: 2990-4.
[3] Degner et al. Information needs and decisional preferences in women with breast cancer. JAMA 1997; 277: 1485-92.
[4] Effective physician-patient communication and health outcomes: a review. CMAJ 1995; 152: 1423-33.
[5] Doyal L. Informed consent: moral necessity or illusion? Qual Health Care. 2001; Suppl 1: i29-33
[6] Coulter A, Entwistle V, Gilbert D. Sharing decisions with patients: is the information good enough? BMJ 1999; 318: 318-22.
Competing interests: None declared
Competing interests: No competing interests