Conversations between doctor and patient about how treatment could possibly lead to the patient's harm or even death rarely happen, according to research.
Whether or facing the prospect of spending a night in the hospital, patients often lack a critical piece of information to make an informed medical decision.
“Risks are not being adequately discussed by physicians with their patients,” says David Magnus, director of the Stanford Center of Biomedical Ethics in Stanford, California.
Research shows doctors frequently talk little or not at all about how treatment could possibly harm patients or even lead to their death, whether they’re being admitted to the hospital for chest pain; undergoing a procedure to get an implantable device used to prevent sudden death from certain heart conditions, such as ventricular tachycardia; having to treat cancer; or discussing general care with a primary care physician.
Conversely, studies evaluating , like one published online in the Annals of Emergency Medicine in March, find physicians often overestimate the risks of not undergoing treatment while also tending to overstate the potential benefits of recommended care.
The recent study, a survey of 425 physician-patient pairs, evaluated perceptions when patients had been admitted to the hospital for possible acute coronary syndromes, which refers broadly to conditions caused by a sudden, decrease in blood flow to the heart, like heart attack.
“The moment of communication we were studying, was a moment where the decision to admit a patient to the hospital had just been made,” says lead study author Dr. David Newman, emergency room physician and director of clinical research at the Icahn School of Medicine at Mount Sinai in New York, New York.
Overall, the research found these vital exchanges were marked by poor communication, overstated risk of heart attack and inflated potential benefits of hospital admission for the patient. In addition, doctors very rarely talked about the , such as hospital-acquired infections.
“I can tell you from experience and combing this data that they virtually never discussed it,” Newman says. “It’s one of the things that was simply missing from the conversation in the great majority of the cases.”
Talking Risk – or Not – Affects Patients’ Care Decisions
Combined with other factors including financial pressures on providers to see more patients and do more procedures, experts say glossing risk – or skipping the discussion altogether – can reinforce another modern medical problem that costs patients in dollars and poorer outcomes: .
“There’s good data to tell us that when patients are engaged in their decisions about their medical care and informed appropriately about harms, benefits and alternatives, they chose less care, not more – and they usually chose it in a way that actually improves their outcome,” Newman says.
That’s significant, he says, because patients face a very real possibility of being harmed by treatment.
He cites in 2013, which estimates that 1 in 145 patients dies from a preventable adverse event, with 210,000 patients dying annually. “The literal estimate is that 0.69 percent of hospital admissions results in a death that was caused by, or importantly contributed to by, a medical error,” Newman notes.
The review seeks to update the Institute of Medicine’s 1998 estimate that medical errors resulted in up to 98,000 deaths annually – a more widely cited figure – by taking into account newer studies.
Whatever the actual figure is today, experts say that both inside and outside the hospital, doctors and patients must discuss the possibility of harm from treatment, alongside potential benefits, as well as alternatives to prescribed care, procedures .
“When a patient is engaged in their own health care and part of the decision-making process, outcomes improve,” says Dr. Kevin Campbell, a cardiologist and cardiac electrophysiologist who specializes in the diagnosis and treatment of heart rhythm disorders and practices at North Carolina Heart & Vascular in three locations: Raleigh, Smithfield and Wilson.
Campbell has been outspoken about the need for physicians to change how they discuss procedures with patients. “I’m a big patient advocate, and I think the days where you have doctors that are very paternalistic in saying, ‘This is what we’re going to do, and this is how we’re going to do it,’ need to be over,” he says.
Discuss Long-Term Effects of Care, Too
For implantable devices, such as or ICDs, that includes discussing upfront the rare but real possibility of recalls, he says, and how patients will be notified if a safety advisory or recall is issued because of a problem with the device.
Campbell says doctors and patients should also discuss the potential long-term consequences of implanting a device, such as psychological effects.
“You now are walking around with a big piece of machinery in your heart that could shock you at any time – hopefully for the right reasons and to save your life – but that takes some adjustment,” he says. “You can develop anxiety disorders, panic attacks, you can be depressed.”
In addition to facilitating more informed decision-making, Campbell thinks discussing risks and side effects, including those that could affect patients in the long-term, may help patients more successfully transition after a procedure.
He adds that open communication allows doctors and patients to be proactive about addressing related health concerns, too. For example, if a patient with heart disease suffers from depression, it might be a good time to talk about following up with a mental health professional before having a device implanted, he says.
If possible, he also suggests patients research their condition or medical issue online, to to ask the doctor before making a treatment decision.