Patient centred diagnosis: sharing diagnostic decisions with patients in clinical practice
BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4218 (Published 01 November 2017) Cite this as: BMJ 2017;359:j4218
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We were delighted to read Berger and colleagues’ analysis of shared decision making (SDM) for diagnostic decisions, an important issue in this era of overdiagnosis and overuse [1]. We agree with the authors that diagnostic decisions represent a unique decisional process before deciding about treatment options [2]. However, we also believe that integrating diagnostic information in SDM tools is essential.
The rationale behind this suggestion is that the probabilistic nature of diagnosis is by itself the first step before guiding patients into treatment decision making. For example, surgery for the knee meniscal tears is increasingly recognized as an overused low-value option for degenerative knee pain [3]. The first step leading to an orthopedic consultation is often a magnetic resonance imaging to diagnose a meniscal tear. Yet, almost one third of all adults will have evidence of a meniscal tear on this imaging test, most of which are asymptomatic and certainly do not require surgery [4]. This is applicable to musculoskeletal disorders like knee, shoulder and low back pain.
Presenting diagnostic information to patients in an understandable manner is one of the most challenging parts of the SDM clinical pathway. In our current studies aiming to foster SDM in the context of prenatal screening for chromosomal abnormalities and fetal infections, we are providing diagnostic probabilities to couples along with screening options [5-8]. This work will provide data on the best ways to improve patients’ knowledge concerning diagnostic probabilities while guiding subsequent treatment decisions. Presenting diagnostic probabilities to patients may strengthen the overall treatment decision making process leading to successful SDM interventions. Only then will we be able to observe that no decisions about oneself is made without oneself!
1. Berger, Z.D., et al., Patient centred diagnosis: sharing diagnostic decisions with patients in clinical practice. BMJ, 2017. 359: p. j4218.
2. Stacey, D., et al., Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev, 2017. 4: p. CD001431.
3. Siemieniuk, R.A.C., et al., Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. BMJ, 2017. 357: p. j1982.
4. Katz, J.N., et al., The Value of History, Physical Examination, and Radiographic Findings in the Diagnosis of Symptomatic Meniscal Tear among Middle-Age Subjects with Knee Pain. Arthritis Care Res (Hoboken), 2016.
5. Portocarrero, M.E., et al., Use of a patient decision aid for prenatal screening for Down syndrome: what do pregnant women say? BMC Pregnancy Childbirth, 2017. 17(1): p. 90.
6. Lepine, J., et al., What factors influence health professionals to use decision aids for Down syndrome prenatal screening? BMC Pregnancy Childbirth, 2016. 16: p. 262.
7. Leiva Portocarrero, M.E., et al., Decision aids that support decisions about prenatal testing for Down syndrome: an environmental scan. BMC Med Inform Decis Mak, 2015. 15: p. 76.
8. http://www.decision.chaire.fmed.ulaval.ca/en/research/projects/pegasus/.
Competing interests: No competing interests
I will keep my response brief. In England, we have a law which covers this: the Mental Capacity Act. For mentally-capable patients, section 3(1) of the MCA is very clear indeed: it amounts to a process in which the patient describes a clinical problem and loosely states an objective [for example 'I've got this back pain which bothers me - can you get rid of it?]; that leads to an investigation of the clinical situation by the doctor, and to the offer of any available treatments which the patient might accept; the offer of a treatment must include a description of its clinical outcomes, and the clinical outcome of no treatment must also be described {and 'outcome' means the probability spectrum of likely consequences of the treatment}; then, once 'adequately clinically-informed', the patient considers the treatment(s) offered and the clinical outcomes, along with any 'wider-life' factors which will affect the patient's decision, and the patient either accepts an offered treatment or declines.
So phrases such as 'sharing diagnostic decisions' and 'patient preferences' are not things I am happy with: the former is confusing expert opinion (the diagnosis) with a decision, and the latter can be perceived as a challenge to where section 3(1) leads, which is to a decision made and expressed by the patient.
mhsatstokelib@yahoo.co.uk
@MikeStone2_EoL
Competing interests: No competing interests
Dear Authors
Please consider Problem Oriented Medical Records (Weed).
Thank you
JK Anand
Old. Patient.
Competing interests: No competing interests
The question of patient centred diagnosis in Old Age Psychiatry can demand consideration not only of which investigations to conduct but also of what to conclude once the results have been received. Increased awareness of and treatment options for dementia over the last 15 years have resulted in patients being referred to Memory Services at an ever earlier stage of cognitive decline and, whilst this supports the admirable aim of timely diagnosis, it also feeds the dilemma over the degree of cognitive and functional impairment necessary for a diagnosis of dementia. Patients with significant functional decline are diagnosed with dementia and offered treatment, whilst those experiencing minimal impact on independent functioning are judged to have mild cognitive impairment and offered annual review.
But what about those borderline cases with a little functional impairment: how much is enough and to what extent might this be confounded by additional physical health concerns and frailty? If we suspect that a patient might have prodromal Alzheimer's Disease, then at what point should we use the 'D' word? This is an inexact science and patient wishes have a crucial role to play in the breaking of bad news and subsequent management decisions. Some have their eyes wide open to the possibility of a degenerative disease and demand treatment at the earliest opportunity. Others are anxious or in denial and would prefer to soldier on for as long as possible without the psychological burden of knowing that they have a terminal illness. Doctors can and should guide, but we must also listen to our patients' wishes and be prepared for diagnostic decisions to be staged through a period of further observation, collaboration and discussion. Watchful waiting can aid both the diagnosis and the therapeutic relationship.
Competing interests: No competing interests
The deepening health crisis promotes the Chinese government to launch a new round of healthcare reform. On October 18th, the 19th Party Congress of the Communist Party of China explicitly stated that China was focusing on constructing the system of primary health care and general practitioners (GPs) education(1). It means that in the next five years or so, GPs in China would increase rapidly in number, and become an important part in the whole medical service system. However, GPs’ status in the eyes of the masses cannot be equaled to that of the specialists in comprehensive hospitals. For example, according to the national statistics, the average number of patients visiting in primary care institutions in 2016 was 4716.6, accounting for only 1/24 of that of comprehensive hospitals (2).
Berger’s viewpoints and case analysis of shared diagnostic decisions with patients have an important implication for GPs in China on improving the quality of primary care and earning patients trust(3). Compared with specialists in comprehensive hospitals, there are three advantages for GPs in China to make shared diagnostic decisions. First, the intrinsic characteristics of primary health care entail that GPs should fully considerate the problems before making definitive decisions. In order to ensure the comprehensiveness of the information from the patients, GPs need to adopt an open and equal attitude when communicating with the patients, listening to their complaints from physical, social and emotional ways. Second, since a majority of basic-level hospitals in China have a limited number of patient visits, GPs own more time to analyze and diagnose the diseases. They could find out the potential health risks of the patients through detailed medical history enquiry and careful physical examination, and avoid making imprudent diagnosis due to over-reliant on the medical instruments. Third, GPs can provide regular health service for the patients signed with them, and frequent interaction is helpful in establishing more stable social connection between doctors and patients. In general, patients tend to discuss their conditions with doctors who they are familiar with, express their opinions on the symptoms and examination, and comply with the decisions they made together (4).
Shared diagnostic decisions can advance the desired outcomes identified by the patients, as Berger mentioned (3), but its realization depends on the joint development of medical personnel and the system. On the one hand, medical administrations should emphasize on motivating GPs to make shared diagnostic decisions, such as introducing alternative payment plans to discourage the episodic care. On the other hand, GPs in China should take positive attitudes towards their professionalism, and keep improving their academic level. Thus the masses will gradually realize that the GPs’ diagnostic ability is no worse than specialists.
1 Xinhua News Agency. Xi Jinping’s report on 19th Party Congress of the Communist Party of China. 2017. http://news.xinhuanet.com/politics/19cpcnc/2017-10/27/c_1121867529.htm.
2 National Health and Family Planning Commission of the People's Republic of China. 2016 national development statistical bulletin of Health and Family Planning. 2017. http://www.moh.gov.cn/guihuaxxs/s10748/201708/d82fa7141696407abb4ef764f3....
3 Berger ZD, Brito JP, Ospina NS, et al. Patient centred diagnosis: sharing diagnostic decisions with patients in clinical practice. BMJ 2017, 359: j4218 doi: https://doi.org/10.1136/bmj.j4218 pmid: 29092826
4 Polinski JM, Kesselheim AS, Frolkis JP, et al. A matter of trust: patient barriers to primary medication adherence. Health Educ Res 2014, 29(5):755-763 doi: 10.1093/her/cyu023 pmid: 24838119.
Competing interests: No competing interests
I find it remarkable, six decades after the Balints published "The Doctor, His Patient and the Illness", that the second interview (Box 2) should have gone as far as it did before the real reason for the consultation came to light.
The Balints taught us to ask words to the effect "Why have you come to see me TODAY?" This question promptly elicits the patient's underlying fear and concerns. It is THE key question I taught all my students.
I would have thought that the Balints' insights would have been integral to GP training for at least half-a-century.
No reference to the Balints in the article. Is their work unknown in the United States?
Somewhat surprising to find this article in a British medical journal in 2017. For Balint followers, it's 'old hat'.
Competing interests: No competing interests
Quality healthcare delivery and Patient centered diagnosis.
Quality health care delivery is one of the prime requirements of modern civilization. Health is the fundamental right of every individual. The Indian constitution considers health to be one of the fundamental rights of its citizens. Medicine is a vast field of service. Now medical care is nothing than ‘a contract between two parties’ i.e. the contract between the patient and healthcare delivered. When we give medical care, the future of the contract should be that you have an obligation to deliver patient-centered health care at a pre-determined price on the day when the contract builds and matures. As in any business it is quite common to do a SWOT analysis; here also the patient has to do a SWOT analysis of the quality of health care he will go to get, cost of the treatment, other alternatives, standards of health professionals, and finally insurance coverage.
In patient-centered health care delivery, the patient has to get very high leverage with some associated risks. If the patient is on the wrong side of the healthcare domain, he can lose money very rapidly. It can even erode his life expectancy. That said, the patient must have basic knowledge about manifestation and appropriate management.
In business management, there is one saying “Keep a stop loss on positions”. This meaning of this saying or principle is a patient should know and give clear instructions to his health care provider regarding his position which may hit him socioeconomically at a certain level. This will ensure the patient limits his losses and may get better health care delivery.
Competing interests: No competing interests