How choice can drive patient engagement

One of my doctors always asks if he can examine me before he starts. He identifies each body part he is going to touch as a question. I feel like I can always say, “No ear exam today, thank you.” Or alternately, “I’ve been having a little pain in my left ear. Can you check it?”

Tiny point. Subtle. But by merely asking me, my doctor signals that I am not a passive recipient of his care but rather an active partner in a series of interactions over which I have some choices. It’s odd that such a minor exchange can have such a potent effect on my impression of my care, no?

The idea that it is time for patients to have a bigger role in determining aspects of our health care has gained considerable momentum over the past decade. The reorganization of care to be more patient-centered, access to patient portals in electronic health records and the use of shared decision-making tools that inject our needs and preferences into treatment decisions are some of the institutional fixes that aim to support our autonomy while simultaneously requiring us to take on more responsibility for our care.

Recent studies in the Journal of Personality and Social Psychology acknowledge the link between personal control and health outcomes, and identify inconvenient layers of complexity:

  • Individuals differ considerably in their preference for making choices about their health care.
    • Individuals’ penchant for choice can vary by situation: type/degree of illness, the complexity of the decision itself, or the setting (office or intensive care unit, for example) can influence people’s interest in making decisions about their care.
    • In addition, some people have a general predilection for more personal control and prefer to make choices about different aspects of their care.
  • Those who prefer to make a specific choice about their care benefit significantly more than those who prefer not to be involved but who nevertheless must choose. The benefit experienced by those who prefer to make decisions is over and above that conferred by the treatment or test (or the choice of none).

The implications of these findings are both practical and expansive.

In an abundance of enthusiasm for ensuring that we are, in fact, actively determining the course of our care, some clinicians are asking their patients to make choices about tests or treatments. Sometimes this happens when formal programs are in place to supportshared decision-making for preference-sensitive conditions such as PSA testing or back pain. In others, clinicians informally – and somewhat haphazardly – delegate decisions to patients: “Yes, I can prescribe a chest x-ray if you are really worried about pneumonia,” or “You decide which migraine drug you want to take.”

Regardless, the data from these studies suggest that when faced with the opportunity to choose, we should always have a clear option to defer decisions about our care to our clinician or a family member. Those of us who are too ill to think clearly, are overwhelmed by the perceived complexity of a specific decision or who simply prefer not to choose should be able to rely on our clinicians to act on our behalf when we are unwilling or unable to do so.

Conversely, many clinicians still have scant enthusiasm for inviting patients to express their opinions and preferences about treatments, tests and care. The objections are familiar: it will take too much time; we may make the wrong choice; we don’t know enough to make an informed decision. The use of shared decision-making protocols for preference-sensitive conditions encourages clinicians to test out sharing decisions with patients about a limited set of concerns in a safe, supervised manner.

But as a patient, I ask you: What aspects of my health care are not preference-sensitive? Even patients who have passed control to a trusted clinician or caregiver are eager to reclaim territory lost. Valuing autonomy and choice over the food we eat, the body part examined or the pills we take, most of us make unilateral (and often uninformed) choices about when and where to seek care and whether or how to make use of it once we receive our clinicians’ directives. As a result, some of our behavior is labeled noncompliant and is viewed as expensive and wasteful.

The invitation — and option — to join with our clinicians in making decisions about all aspects of our care will not necessarily improve our adherence to medical directives. Rather, having the choice to work with our clinician to agree on a treatment plan that matches our preferences increases the probability we follow that plan and, in the process, reap additional benefits from participating to the extent that we are willing and able.

Jessie Gruman is the founder and president, Center for Advancing Health. She is the author of Aftershock: What to Do When You or Someone you Love is Diagnosed with a Devastating Diagnosis. She blogs regularly on the Prepared Patient blog.

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  • guest

    Just speaking for myself that would drive me crazy. I am at the doctor for a problem that I wish him to evaluate and advise treatment for. I would find it precious beyond belief for him to request my permission for each part of the physical exam, and would not return to see anyone who wasted our time together in that way. So in my case, the approach described above would drastically reduce my engagement with care.

    That’s the great thing, and also the problem, with medicine. We are all different, with different preferences, so there will never be one cookie-cutter approach we can mandate which will be effective and appropriate for all patients.

    • SarahJ89

      You’re probably not one of the one in four women in the US who was molested before her 18th birthday. Which, if so, is wonderful. You are correct–one size does not fit all. Doctors probably should ask about a patient’s need before laying hands upon him/her initially. The exam can then proceed down the path required by the patient.

      I can only wish doctors would be honest about side effects (type and prevalence) and contraindications of the meds/test/treatments they offer. But that’s not likely to happen in my lifetime. Until it does there can be no meaningful doctor-patient collaboration. And docs are not being allowed the “luxury” of time nowadays.

  • Edward Leigh, MA

    Great post! Your bring up many important points about shared decision making. The patient-clinician relationship is no longer a parent-child relationship. I coach drs on communication skills. I think it is great your dr asks permission, however I think it would be acceptable to ask in the beginning, “May I examine you now?” I don’t think permission is needed for every body part. If we could just get more clinicians to use empathy on a regular basis! Once again, excellent post! Best, Edward Leigh, MA, Center for Healthcare Communication

    • rbthe4th2

      Agreed on a great posting. I’ve had too many doctors fail to diagnose/misdiagnose, then say I was non compliant when I wouldn’t agree to the incorrect assessment. The relationship for many doctors is still paternalistic. Its still ‘I am in demand, so I will leave you without health care AND a reputation if you don’t do as I say’. Not all, mind you, but a lot. Including when they’re confronted with medical literature that goes against their own thinking, they’re unwilling to try a new tact.
      Its like it is all about the doctors’ ego and not about the patient getting better, no matter who is right or wrong. Aren’t we all in this together?

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