Your Medical Mind_ How to Decide What Is Right for You - Jerome Groopman [106]
65 Between November 2006 and May 2007, researchers at the University of Michigan conducted a national survey of medical decisions, contacting by telephone at random 3,100 adults forty years and older in the United States. Participants were asked a series of questions about nine common medical decisions they might have discussed with their doctors in the previous two years. These medical decisions included initiating prescription medications for high blood pressure, elevated cholesterol, or depression; screening tests for colorectal, breast, or prostate cancer; and surgeries for low back pain, cataracts, or knee or hip replacement. Of these nine decisions, 82 percent of the people surveyed had made at least one in the preceding two years, and 56 percent had made two or more. Seventy-two percent had discussed at least one cancer screening test, 43 percent considered taking at least one of the medications, and 16 percent had discussed one or more of the surgical interventions. There were approximately 130 million adults aged forty years and older in the United States in July 2006, so extrapolating from the survey, about 33 million adults discussed initiating medication for elevated cholesterol, 27 million for high blood pressure, and 16 million for depression; more than 10 million considered cataract surgery and about 7 million considered an operation for low back pain or to replace a diseased knee or hip. Less than half the patients recalled being asked about their preferences regarding cholesterol medications or blood pressure medications. This finding contrasted with patient reports that in more than 80 percent of instances, the physician expressed his opinion about initiating drug treatment for hypertension or elevated cholesterol. About a fifth of the patients did not recall being asked their preferences for surgery for low back pain or joint replacement. Perhaps most striking was that in the discussion between the doctor and patient, a disconnect occurred in presenting the pros and cons of therapy: in more than 90 percent of cases, there was a discussion of benefits of treatment (pros or “reasons to act”) for medicating high blood pressure or elevated cholesterol, but in less than 50 percent the cons or “reasons not to act” were discussed. Discussions about surgery were more balanced, with 60 percent of the cons aired for hip or knee replacement, 80 percent for low back surgery, and about 40 percent for cataracts. Thus overall, discussions were weighted toward reasons to act much more frequently than reasons not to act. See: Brian J. Zikmund-Fisher et al, “The decision study: A nationwide survey of United States adults regarding 9 common medical decisions,” Medical Decision Making 30 (2010), pp. S20–S34; Brian J. Zikmund-Fisher et al., “The decision study: A nationwide survey of United States adults regarding 9 common medical decisions,” Med Decis Making 30 (2010), pp. S20–S34; Brian J. Zikmund-Fisher et al., “Deficits and variations in patients’ experience with making 9 common medical decisions: The decisions survey,” Med Decis Making 30 (2010), pp. S85–S95; Neda Ratanawangsa et al., “Race, ethnicity, and shared decision making for hyperlipidemia and hypertension treatment: The decisions survey,” Med Decis Making 30 (2010), pp. S65–S76. A critique of the survey: Stephen G. Pauker, “Medical decision making: How patients choose,” Med Decis Making 30 (2010), pp. S8–S10. An analysis of its implications: Floyd J. Fowler, Jr., Carrie A. Levin, Karen R. Sepucha, “Informing and involving patients to improve the quality of medical decisions,” Health Affairs 30 (2011), pp. 699–707.
66 There is a powerful imperative to standardize medical care and follow guidelines strictly; see Stephen J. Swensen et al., “Cottage industry to postindustrial care: The revolution in health care delivery,” NEJM 362 (2010), pp. E12(1)–E12(4); Robert H. Brook, “A physician = emotion + passion + science,