Doctors misjudge patient preferences

DOCTORS frequently misjudge patients’ preferences regarding treatment, according to research from the US and Wales.

The gap between what patients think about treatment options and doctors’ perceptions of patients’ priorities is often considerable, researchers found. They say this so-called “preference misdiagnosis” is a common problem that is damaging patients as well as increasing healthcare costs.

The analysis, published on bmj.com, found that in one study only seven per cent of breast cancer patients rated keeping their breast as a top priority. In contrast, doctors thought the majority of their patients (71 per cent) would rate this as the most important factor when deciding on treatment. And although doctors thought that living as long as possible would be the top priority for 96 per cent of breast cancer sufferers considering chemotherapy, the figure was actually only 56 per cent.

Another study showed how doctors placed a far higher value than dementia patients on the continuation of life with severely declining cognitive function.

The authors found evidence that once patients are properly informed about the risks and benefits of treatments, they often make different decisions about treatment. For example, when men are told of the risks of sexual dysfunction following surgery for benign prostate disease, 40 per cent fewer said they preferred surgery.

The report argues that doctors cannot recommend the right treatment without understanding how the patient values the “trade-offs”, but adds that preference misdiagnosis generally goes unnoticed.

Doctors need to do more than simply ask a patient what they want, the report says. The first step is to break the patient’s expectation of being told what to do and instead engage in “team talk”, combining the doctor’s medical expertise with the patient’s expertise on their own priorities. The doctor should then present a list of options and explain the risks, benefits and side effects of each, being sure to observe the verbal and non-verbal cues from the patient. Some patients will then be confident enough to make their own decision regarding treatment.

While this sounds obvious, the authors highlight the fact that a patient’s treatment preference is “just an opinion based on what the patient knows at that moment” and may change as they learn more information. They recommend seeking out “patient decision support tools” to assist in the process.

Where a patient asks their doctor to recommend a treatment option, and the doctor is confident they have correctly diagnosed the patient’s preferences, they should confirm their understanding of the patient’s priorities for different health outcomes and then offer a recommendation. If not, the doctor should seek to better understand the patient’s priorities.

The authors conclude: “Evidence from trials shows that engaged patients consume less healthcare. More work is needed to understand the magnitude of this potential benefit, but it is tantalising to consider that budget challenged health systems around the world could simultaneously give patients what they want and cut costs.”

Read the study at: http://www.bmj.com/content/345/bmj.e6572