Patients are not to blame for the miscommunication about cardiac stents

When I had a heart attack two years ago, I was taken immediately from the E.R. to the O.R. for emergency treatment, including cardiac catheterization and a stainless steel stent implanted in a major coronary artery that was 99% blocked. But, overwhelmed and terrified, I knew nothing about what was about to happen, even though I have a vague memory of the cardiologist explaining something to me before I was whisked upstairs. I don’t think I was capable of paying attention at the time. What I learned much later was that the stent can help a newly-opened artery stay open.

But a new study now suggests heart patients believe that stents have greater benefits than they actually do, the Boston Globe reports.

The research, published in the journal Annals of Internal Medicine, found that over 80% of heart patients who had undergone angioplasty with cardiac stents implanted thought that the procedure would cut their odds of having a future heart attack. But about the same proportion of physicians reported to researchers that they had told their patients that stents would do nothing more than simply relieve chest pain.

The Globe calls this a “yawning disconnect between what doctors say and what patients hear.” It extends to other types of elective medical treatment as well, resulting in patient confusion and even overuse of some procedures. Cancer patients, for example, may believe chemotherapy will destroy a tumour, counting on a cure when medical evidence does not promise that.

Dr. Henry H. Ting from Mayo Clinic told a HealthDay interviewer that he was not surprised by the study findings. He pointed to another Mayo Clinic survey that found that 80% of patients signed consent forms they had not read, and did not know the benefits or risks of the treatment they were having.

Ting, who conducts research on informed consent, said the problem of patient understanding isn’t limited to cardiac procedures but is common in many areas of medicine: “We [doctors] don’t do a good job of knowledge transfer in a way that patients and family members can understand. Graphs and charts are not going to work for many of our patients.”

One reason for patients’ misunderstanding is the common belief, cited in the recent study, that if a treatment is offered, it must have curative benefits.

And apparently some cardiologists are equally confused.

According to the study’s authors, for example, less than one-third (31%) of those who agreed to undergo elective cardiac catheterization actually had the type of activity-limiting angina pain that angioplasty might even be expected to ease. Which may make you wonder why the procedure was done on two-thirds of these people in the first place.

The authors also noted that treatment benefits can often be achieved with medication alone.

Nevertheless, almost three-quarters of all the patients studied still believed that if they didn’t undergo angioplasty, they would suffer a heart attack within the next five years. Where did they get this from?  Study authors admit that they were not present during “informed consent” discussions between patient and doctor, and so had to rely instead on what cardiologists told them they’d said to patients.

Only patients who are actually having a heart attack or coronary event can expect angioplasty or stent implantation to reduce risk of future heart attacks and death, according to 2007 research cited in the study.

Dr. Richard Frankel, a Regenstrief Institute research scientist at the Indiana University School of Medicine, offers this observation on the classic doctor/patient miscommunication problem: “We don’t assume that when a pilot and an air traffic controller converse that they have understood each until there is an affirmation of understanding. That acknowledgement is lacking in most patient-physician encounters.”

Dr. Frankel, who studies ways to improve the doctor-patient relationship, is currently investigating how behavioural changes by both doctors and patients impact medical care. He adds: “From previous work, including a well-regarded 1999 study from the University of Washington, we know that doctors ask patients whether they understand what was just discussed less than 2% of the time. Doctors should be trained to routinely check for understanding to ensure that there is neither miscommunication nor mismatch between what the patient wants and what doctors assume the patient wants.”

Patients are not to blame for that miscommunication about cardiac stents, says Dr. Michael Pignone, a medical editor for the Boston-based Foundation for Informed Medical Decision Making.

I tend to agree with Dr. Pignone. For starters, when two people who are on equal footing are communicating calmly using a similar knowledge base, we might assume a reasonably good level of mutual comprehension.  Two auto mechanics can talk shop together trusting that they absolutely understand each other. Ditto for two oceanographers. Two accountants. Two computer programmers.

But just try putting one of two people in a drafty hospital gown, lying scared and vulnerable on an E.R. stretcher and suffering distressing symptoms, while the other person stands overhead coolly rattling off a jargon-filled explanation of what may or may not happen next. It’s a tragic recipe for miscommunication.

As the person in the drafty gown, should it be up to the patient to ensure that doctor-patient communication is accurate or effective during a distressing medical emergency?

Carolyn Thomas is a heart attack survivor who blogs at Heart Sisters.

 

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