Patient choice is the new normal in medicine, except for in cancer treatment

by Ruth Nichol / 21 August, 2018
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Cancer specialists could do better in discussing treatment options with patients, a new Victoria University of Wellington study finds.

Now that the “doctor knows best” mentality has been consigned to the scrapheap, doctors are not meant to tell us what to do. Instead, they’re supposed to present us with a range of options then help us decide which one to choose – what’s known as shared decision-making.

Or at least that’s the ideal, and although it’s not always possible – during a medical emergency, for example – shared decision-making has become a routine part of many medical consultations.

But a recent study by Victoria University of Wellington academic Kevin Dew, who specialises in the sociology of health and illness, has found that when it comes to decisions about cancer treatment, doctors almost never engage in shared decision-making with their patients. Based on a close analysis of transcripts from 18 cancer-care consultations, he found that the only time patients were offered a choice between different treatments was when the clinical outcome was likely to be poor whatever they did.

In most situations, doctors either explicitly recommended a particular treatment or provided information about different possibilities, but made it clear which one they favoured – effectively giving patients little or no choice in the matter.

Although Dew supports shared decision-making in principle, he thinks that cancer treatment should possibly be an exception.

“I think there’s something about the fact that this is potentially a terminal illness, which means it does play out differently. The study suggests that when your life is dependent on it, people feel happier not having to make decisions.”

He says that if you go to see your GP with a cold, it will go away whatever you do, so the treatment you choose doesn’t really matter. “But with cancer, it’s a life-and-death situation, and the decisions can be so consequential.”

Kevin Dew: patient choice is important.

In some cases, patients said quite clearly that they wanted the doctor to make the decision for them. When “Peter”, who had prostate cancer, was asked, for example, what his expectations were, he replied, “Pretty much doing what I’m told.”

Dew says cancer patients may see following the doctor’s orders as preferable to making a decision themselves. “If you make the decision yourself, and you end up dying two years later, you’re going to blame yourself. But if someone else makes the decision, and you end up dying after two years, you don’t blame yourself.”

But rather than seeing the fact that cancer-care specialists don’t engage in shared decision-making as an indictment on the way they work, Dew suggests that it may be better to reframe the concept of shared decision-making in this context. Instead of asking patients to decide what treatment they want, they could instead be asked to decide how much information they want, and who they want to be responsible for making decisions about their treatment.

“I don’t know how that would work in practice and we shouldn’t presume that there are people who wouldn’t want to make a decision. I think there’s a wider debate about what level of involvement patients want. In the case of cancer treatment, shared decision-making could come at the very beginning of the process, when patients make a decision about whether they want to be involved or not.”

Dew’s analysis is part of a larger study looking at cancer care in New Zealand. He and his colleagues have also analysed transcripts from 10 multidisciplinary meetings of healthcare professionals providing care to 106 people with cancer. This analysis found that although a lot of objective data and technical information was presented at the meetings, participants also brought up much more subjective information. For example, in one case a clinician expressed the view that because a patient worked as a colour therapist she would probably turn down the offer of surgery.

The analysis also found that patients who had not been seen in person by anyone at the multidisciplinary meeting tended to be at a disadvantage. One way of solving this would be to connect by videoconference with doctors who had seen them – something that is routinely done in Britain

“The clinicians themselves found our results quite revealing,” Dew says. “When we showed the data to one clinician, she told us that she immediately changed her behaviour.”

This article was first published in the August 11, 2018 issue of the New Zealand Listener.

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