Lee A. Resnick, MD, FAAFP
“Patient empowerment,” “patient-centered care, “patient-focused care,” and “shared medical decision-making” are among a growing number of terms intended to shift the power and control of healthcare decisions from physicians to patients. The concepts are, for all intents and purposes, accepted as “good.” It is merely assumed that empowered patients are better off than those who defer control of their healthcare decisions to their clinicians.
Despite an almost revolutionary change in the way we practice medicine, little or no research has ever been done to challenge the purported benefit. Are patients always better off when decisions are in their own hands? What are the risks? What is the pay-off?Are there unintended or unexpected consequences?
It is easy foralayperson to assume that an informed and empow- ered “consumer” is better off than an ignorant one. As a matter of logic, being informed allows for more intelligent decision-making and protects the consumer from falling prey to a slick sales pitch. As “consumers” of healthcare, then, one might easily presume the same applies, and no one would argue that to a certain extent this istrue.
Informedpatientsaremorelikelytobecompliant,andinsome cases, to make more cost-effective healthcare decisions.
In general, consumer empowerment works best when four conditions exist: 1) The information needed to make an informed decision is finite and consumable; 2) There is a clear distinction of personal value between the options; 3) The risk of being wrong confers the lowest risk; and 4) The potential risk to the public good is minimal.
But how well does that apply to medical decision-making? How might the approach break down, or even backfire?
The challenge with medical decisions, of course, is that the information required is immense, the best option is often unclear, the risk of being wrong is potentially catastrophic, and consideration for public health is imperative. In fact, the whole purpose of educating ourselves into our 30s with hundreds of thousands of dollars in educational debt is in support of consuming in describable amounts of information and learning the contexts within which this information needs to be applied. The potential for consequence and harm demand expertise and dedication to service devoid of self-interest. This is not a field for weekend warriors or amateur enthusiasts. Yet more and more, the patient (errr, consumer), demands power and control over the decision-making to the extent that, dare I say, the best decisions are not always made. In addition, most patients under- appreciate the painful consequences of empowerment when the risk and uncertainty is high. Consider these examples:
- “Consumer demand” for antibiotics when they are not indicated has produced a public health crisis driven by resistant pathogens, innumerable adverse reactions(many deadly),and unnecessary healthcare costs in the billions of dollars
- Complex healthcare decisions involve stratospheric amounts of information that must be processed in ever-shorter periods of How, for example, can you really define the need for hospitalization to a patient with chest pain of uncertain origin? Are we to review the meaning of the TIMI score and quantify the risk? What real meaning does that have for most patients?
- It is incumbent upon someone who is given responsibility and control of decision-making to look cynically at those contributing data and information for fear of being bamboozled or misled. Trust, on the other hand, requires vulnerability and transfer of control to the other party.Most every one appreciates trust as a paramount characteristic of the doc- tor-patient relationship. Yet, I have heard no one express concern for this potential consequence of the patient empowerment revolution.
I am, by no means, recommending a reversal of patient-centered care. I am, in fact, a strong proponent of patient involvement and shared decision making. But I implore everyone to pause long enough to appreciate the hidden potential for harm. We must ask the difficult questions in the interest of public health and the future of the profession. Framing these questions without insulting an ever-demanding and empowered public will be a challenge…filled with the same uncertainty and unpredictability we have endured for centuries.