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Sorry, Doc, that doesn't fit my schedule (Feb-04)

Patients sometimes skip treatments because they just feel too busy. What should physicians do when their patients ignore their recommendations?

Imagine you are a businessperson who works long hours and you are on your way up to having a successful and lucrative career. You have a major business deal that will consume nearly all of your time over the upcoming month and your boss is relying on you to make sure the deal goes through. This is your chance to really make your mark and show your corporation that you are the kind of person that can handle deals as big as this one. Also suppose you have been smoking on and off for 25 years. You know it's a bad habit that could destroy your lungs, but you just can't quite kick it. Lately, you have been feeling tired, you have been experiencing chest pains when you are really busy at work and when you exercise, and you have had trouble breathing when climbing a flight of stairs. The chest pains are usually relieved by a little rest, but you decide it's time to get this examined by a doctor.

One day after work, you go to see Dr. Coral, who gives you a stress test and determines that you'll need an appointment for an angiogram to better evaluate your coronary arteries. Fortunately, you find one free day right before things get hectic at work, so you schedule the angiogram. Now imagine you have just had the angiogram and you are recovering in a paper gown waiting for Dr. Coral to come back with the results. Dr. Coral enters the room to speak with you and he has a serious look on his face. He says,

"I have both good and bad news for you. The angiogram shows that your 3 main coronary arteries are all severely blocked. The good news is that we caught this before you had a major heart attack."

"The bad news is that I am recommending you have triple bypass surgery as soon as possible. Your heart is working overtime, and it is just a matter of time until it gives out."

The news is shocking, but in addition to your health concerns, you also have the business deal to worry about. This deal is an opportunity to make a name for yourself, and your boss has been very vocal that he was counting on you, trusting that you'd be the one for the job. You find yourself having to weigh your work ambitions against the recommendation from Dr. Coral because if you get surgery, there is no way you'd be able to take on your current work responsibility.
 
Which of the following decisions would you be most likely to make?
 
  • I would put aside Dr. Coral's recommendation and instead take responsibility at work for the current deal. I'll wait to have surgery in about a month.
  • I would follow Dr. Coral's recommendation by having surgery immediately, even though this forfeits the current opportunity at work.

A little feedback on what you chose.

It's not that physician's don't care about your other values, but they are primarily concerned about your health, and you might not even have lived long enough to finish the business deal if you didn't have this surgery immediately. This does, however, bring up an important fact: patient's do sometimes reject their physician's medical judgment, and it can be at a great cost to their health.
 
Why should a patient be part of the decision-making process?
 
Why shouldn't Dr. Coral just tell you that you need surgery and leave no alternative? Efforts to share decision-making with patients are important because they acknowledge patients' rights to hold views, to make choices, and to take actions based on personal values and beliefs. In addition to being ethically-sound, this shared decision-making process also leads to improved patient health outcomes.
 
What can a physician do to help the patient choose surgery?
 
To answer this question, first it needs to be emphasized that in order for a patient to be able to participate in the decision-making process, the patient must be able to soundly make decisions. This sounds abstract and subjective, but it can be broken down into something a little more concrete. Decision-making capacity (DMC) is based on four guidelines:
 
The patient is able to:
 
  • understand the information about the condition and the choices available;
  • make a judgment about the information in keeping with his or her personal values and beliefs;
  • understand the potential outcomes or consequences of different choices; and
  • freely communicate his or her wishes
Based on these four elements, it is possible to see what a physician can do to help facilitate a "good" health decision. In order to make sure a patient fully understands the situation, a physician can ask him or her to state their understanding of the problem and of the treatment options. Also, a physician should use clear and unambiguous language with the patient at all times. Although a report might be quite clear from a physician's perspective, a patient might not be as clear about all the details. In the situation you were asked to imagine, Dr. Coral should tell you that you will die without this surgery and that waiting is not a safe option.
Also, there might be other factors keeping a patient from following a physician's recommendation. Again, in your hypothetical situation, your boss was putting a lot of pressure on you not to let him down. Also, this decision would potentially have an effect on your advancement at work. You might not have felt free to elect surgery even if you knew it was the only good decision for your health. By directly acknowledging and addressing a patients' concerns, physicians may facilitate a decision for the surgery.
 
In conclusion, if a physician feels that a patient is not able to fulfill one or more of the elements of DMC then his or her ability to make that decision should be brought into question and surrogate decision makers should be sought. For more serious decisions, the standards for DMC should be higher than for less important decisions or those with less significant outcome differences among the choices.
 
For more information see:

 

Thu, February 04, 2010

Angela Fagerlin, PhD, talked with Financial Planning about how research on decision aids in healthcare might be used to help financial planners convey complex information to their clients. She discussed specifics: use of absolute vs relative risk data, frequencies vs. percentages, and graphical representations such as bar graphs and pictographs. 

Health Communication and Decision Making

A major theme of CBSSM involves using techniques from basic and applied research to determine the best practices for communicating health information to patients and the public more generally. This special interest group explores topics related to understanding and improving patient and public decision making about medical issues.

Research that falls within this programmatic area includes topics such as:

  • Risk communication and perception
  • Health communication and education
  • Development and testing of decision aids/patient education materials
  • Visualization and contextualization of health data
  • Communication of genomic information to patients and providers
  • Numeracy and literacy
  • Utility and survey methods
  • Patient decision making
  • Patient-physician communication

CBSSM Seminar: Jacob Solomon, PhD

Thu, November 19, 2015, 3:00pm to 4:00pm
Location: 
NCRC, Building 16, Room 266C

Jacob Solomon, PhD


CBSSM Postodoctoral Fellow

Title:

Designing the information cockpit: The impact of customizable algorithms on computer-supported decision making

Abstract:

Intelligent systems that provide decision support necessitate interaction between a human decision maker and powerful yet complex and often opaque algorithms. I will discuss my research on end-user control of these algorithms and show that designing highly customizable decision aids can make it difficult for decision makers to identify when the system is giving poor advice.

Funded by NIH - Department of Health and Human Services

Funding Years: 2012-2017

Treatments for cancer impose substantial burden and morbidity but net survival benefit of different strategies is often small and virtually always uncertain. Thus, clinicians may do more harm than good if treatment is too aggressive. There are a number of management strategies for breast cancer aimed at reducing unnecessary morbidity and burden on patients with favorable disease. A key barrier to advancing these initiatives is the need for a better understanding of the challenges of individualizing cancer care. The goal of this program is to improve population health by helping clinicians and their patients address the challenges of individualizing treatment of breast cancer for patients with favorable prognosis. Objective 1: To examine the challenges of individualizing treatment for women with breast cancer. Two projects will each undertake an observational study of patients newly diagnosed with breast cancer (including their attending clinicians) who were reported to the SEER registries of Georgia and New Jersey during an 18 month period to examine patient and clinician factors associated with key evaluative tests, treatments, and patient appraisal of decision quality. Project 1 will focus on challenges for surgeons and their patients with regard to locoregional therapy. Project 2 will focus on challenges for medical oncologists and their patients with regard to systemic therapy. Objective 2: To improve treatment decision quality. Project 3 will perform a randomized controlled trial of a practice based online decision tool for patients newly diagnosed with breast cancer in the Detroit and Atlanta SEER regions intended to improve decision quality. Objective 3: To accelerate the dissemination of SEER-based research findings by implementing and evaluating a tailored online portal aimed at all surgeons and medical oncologists who treated the patient samples in P1 and P2 to evaluate whether our research findings can more directly and promptly inform clinicians knowledge and attitudes about individualizing treatment. Objective 4: To advance methods in SEER population translational research focused on quality of cancer care. We propose four shared resource cores that will support program project activities, advance innovative methods in oncology population sciences, and advance team mission and long-term strategic planning.

PI(s): Steven Katz

Co-I(s): Lawrence An, Michael Elliott, Angela Fagerlin, Sarah Hawley, Timothy Hofer, Reshma Jagsi, Nancy Janz, Yun Li, Kenneth Resnicow, Jeremy Taylor, Christopher Friese

Funded by National Institutes of Health.

Funding Years: 2011-2016

 

Making decisions about the medical care of a loved-one with acute brain hemorrhage is a difficult and frightening time for families. This project will work to improve the processes that doctors and families use to make these decisions in the future. For more information, visit NIH Reporter

PI(s): Darin Zahuranec, Brisa Sanchez

Co-I(s): Renee Anspach, Angela Fagerlin, Lewis Morgenstern, Phillip Rodgers

 

 

Funded by American Cancer Society.

Funding Years: 2014-2017.

The study will examine how informal decision supporters (e.g., partners, family, and friends) contribute decisions about surgery, radiation, and chemotherapy treatment, and how these roles may vary by race and ethnicity. The project will utilize existing resources from the Cancer Surveillance and Outcomes Research Team's (CanSORT) Program Project Grant "The Challenge of Individualizing Treatments for Patients with Breast Cancer," a $13 million award received from NCI in 2012.

PI(s): Sarah Hawley

Co-I(s): Jennifer Griggs, Nancy Janz, Steven Katz, Yun Li

 

CBSSM researcher Brian J. Zikmund-Fisher, PhD, and collaborator Mick Couper, PhD, from the UM Institute for Social Research spoke to the Medical Editors Meeting of the Foundation for Informed Medical Decision Making in Jackson Hole, Wyoming. Drs. Couper and Zikmund-Fisher reported on "Methods and Early Results from the National Survey of Medical Decisions." This pioneering survey reveals surprising information about the epidemiology of ten common medical decisions that are made by older Americans. Discussion of the presentation was lively!

The Foundation for Informed Medical Decision Making, which funded this CBSSM research, is a nonprofit organization dedicated to assuring that people understand their choices and have the information they need to make sound decisions affecting their health and well being.
Learn more at http://www.fimdm.org

Sun, October 17, 2010

Brian Zikmund-Fisher, PhD, was featured in an interview by the U-M News Service on September 29, 2010.  Dr. Zikmund-Fisher served as the featured guest editor for a special supplement to Medical Decision Making, Sept/Oct 2010, that focused on the DECISIONS study. In the interview, Dr. Zikmund-Fisher highlighted the need for health care providers to do a better job of educating patients about the medical decisions they face.  A video highlights the findings of the study and can be found at: http://ns.umich.edu/htdocs/releases/story.php?id=8008.  CBSSM faculty also involved in the DECISIONS study included Angela Fagerlin, PhD, and Mick Couper, PhD

Amanda Dillard, PhD, was awarded a $25,000 George Bennett Postdoctoral Grant by the Foundation for Informed Medical Decision Making. With this funding, Dr. Dillard will conduct surveys to examine whether certain types of patient testimonials have a beneficial influence on knowledge, satisfaction, and interest in shared health care decision making, specifically in the context of a decision aid related to colon cancer screening. She will use social cognitive theory, social comparison theory, and risk processing perspectives to guide her hypotheses about testimonials.

Dr. Dillard’s postdoctoral position at CBSSM was funded by VA Health Services Research and Development, Ann Arbor, Michigan.

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