The Cost of Assuming Doctors Know Best

The success of a hospital system in Washington state is a strong signal that patient decision aids are powerful quality-improving, cost-cutting tools -- but change is stalled by bad financial incentives.

Group Health Cooperative, Bellevue, Washington (BenjaminBenschneider/AECOM)

In most industries, quality-improving and cost-cutting innovations don't sit around for years while people keep muddling through with old technology. When an innovation is ready for widespread use, it disrupts the market, whether the market wants it or not. In the process, some entrepreneur usually makes a killing.

That process hasn't worked in healthcare, though -- and because of that, we have a whole set of rarely-used innovations that are ready for large-scale implementation, and that could start saving money today. Those technologies include simple things like broader use of generic drugs, which can reduce pharmaceutical costs significantly; and better hand washing, which reduces the transmission of disease within hospitals and doctor's offices. They also include more complicated interventions like Lean management, which has been implemented successfully at hospitals like Virginia Mason Medical Center in Seattle and Thedacare in Wisconsin, to make their care processes more efficient by cutting out useless steps.

The habit of assuming the doctor knows best has created a system where huge numbers of patients aren't getting the treatment they would have chosen if they were fully informed.

Then there's shared decision making, which helps patients be better informed about their treatment choices and make better decisions -- and might be the most promising of the bunch in terms of improving care and reducing spending.

Shared decision making is a way of dealing with the tough questions posed by "preference-sensitive conditions" -- conditions where there are multiple treatment options, and none of those options is clearly better than the others. That includes conditions like arthritis in knees and hips, low back pain, stable angina (chest pain from heart disease), and early-stage prostate and breast cancer. (Obviously, it doesn't include emergency conditions like heart attacks and hip fractures, or conditions where there is clearly only one treatment.)

Deciding on a treatment for preference-sensitive conditions involves weighing a variety of risks and possible benefits, and different patients will end up making different "right" decisions because they have different values and preferences. The best example here is women with early-stage breast cancer. They can choose lumpectomy (surgery that preserves the breast) or mastectomy (which removes it entirely). The two options are equally good in terms of reducing the risk of dying of breast cancer, but they require different kinds of follow-up and different women prefer one over the other.

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Making such decisions means that patients must have the relevant information about all their treatment options, and doctors must understand their individual patients' preferences -- basically, what they want from treatment. But too often, patients only hear about one treatment option, the one the doctor usually uses -- and doctors routinely assume they know what their patients want without actually asking them. And in many cases, the doctor is wrong.

This habit of assuming the doctor knows best has created a system where huge numbers of patients aren't getting the treatment they would have chosen if they were fully informed. It also means that hundreds of thousands of patients are going through surgery that wasn't really worth it, and that they wouldn't have chosen had they understood their options.

Shared decision making is a process designed to ensure that patients are fully informed, and then use that information to get the treatment they want. A common though non-essential part of informing patients is a "patient decision aid." Decision aids can be videos, websites, or pamphlets, and they present the available medical evidence on all reasonable treatment options -- including the option to do nothing -- in a way that patients can understand. Decision aids also help patients understand what they value and how much risk they're willing to accept. Doctors can participate in the process, too, by clarifying things for the patient and helping make sure there's a good match between the treatment and what the patient wants.

There have been more than 80 randomized controlled trials on the effects of patient decision aids, and the results are pretty clear. According to the Cochrane Collaboration, which reviews groups of studies, using patient decision aids improves the match between patients' preferences, improves patients' knowledge of the possible results of treatment, and reduces the number of patients who still don't know what they want.

Here's the icing on the cake in terms of health care spending: Patients also tend to choose less invasive (and therefore less expensive) treatment options.

Presented by

Shannon Brownlee & Joe Colucci

Shannon Brownlee is the acting director of the health policy program at the New America Foundation and an instructor at the Dartmouth Institute for Health Policy and Clinical Practice. Her writing also appears in The New York Times Magazine and The New Republic. Joe Colucci is a program associate in the New America Foundation's Health Policy Program.

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