Physicians see process as one of collaborating with patients

June 22--With the advent of the internet and online medical sites, patients know more about their conditions now than in the past, and physicians are more open to their participation in making health care decisions.

In years past, physicians made decisions and the patients went along with them.

But while physicians are still the medical experts in the the doctor-patient dynamic, some of them now see their role as one who lays out treatment options and either collaborates with the patient on a course of action or leaves the decision up to the patient.

"I tell my patients, my role is not to tell them what to do but to give them guidance," said Dr. Khanh Nguyen, a physician with Owensboro Health Family Care. "It's up to them whether they want to use that guidance or not.

"If we tell patients what to do, that doesn't allow them a feeling of ownership of their care. I really want them to have ownership."

Dr. Chris Toler, chief medical officer of Owensboro Health Medical Group and an OB/GYN, said "anything you do, a patient should have their input.

"It requires buy-in from the patient in order to get the outcome you want," he said. "A physician just can't make decisions unilaterally like that. They need to involve the patient and meet them where they are in their life.

"If someone lives alone and they need to do X, Y, or Z, that may not work out if they don't have someone there at home to help them, so you might need to think about a different kind of treatment for that patient. So a physician will lay out a spectrum of options from something completely noninvasive to the most aggressive option, and we try to find out where we're at on that spectrum and see what fits the patient best."

Toler said surgery for someone 25 years old with three children may not be as appropriate as for someone in their 50s. But that decision ought to be the patient's once the pros and cons of every option are explained, he said.

Basically, there are three models of the doctor-patient relationship -- the doctor makes decisions, the patient makes decisions or the two share in the decision-making.

Health care officials say that even when a doctor is the one deciding on a course of action, he or she should still give a patient a rundown of the situation, answer questions and explain treatment options.

In a 2005 study at Baylor College of Medicine, researchers interviewed 53 physicians about how and why they went about making clinical decisions. One surgeon said, "I didn't go through 16 years of study to let people make their own decisions." Another said that that's why people came to him -- for him to treat them based on his knowledge and experience.

Some health care officials said the current culture has shifted as patients want to have a larger say in what's going to happen to them. It's their life, after all. Also known as the consumer model, the physician provides factual information after examination and testing, and the patient makes the ultimate decision about which treatment option works best, as if picking from a menu.

"There are a lot of high deductible health plans right now, and patients are becoming consumers," Toler said. "They're looking for quality, which we are always working toward, and we've achieved, but the deductibles are so high, it's almost like not having insurance, and they end up paying so much out of pocket."

And that's one of the challenges confronting health care -- a physician knowing what's best for a patient while facing the reality of what a patient can afford, or is willing to pay.

"Physicians may know what's best, but from a whole-person standpoint, sometimes we miss that part of the picture," Toler said. "You can prescribe the best medicine and the best treatment, but if the patient can't afford it, or he's not engaged enough to do it, then the treatment isn't the right one for that patient.

"That's what we're trying to change, making sure the right care gets to the right patient. It's not a one-size-fits-all model."

Faced with options, some patients may be indecisive or not in the best frame of mind to decide what to do, particularly if they are confronted with surgery and major life changes. Many will trust the physician to guide them to the right answer.

"I want to make sure I manage their care responsibly by not ordering additional tests if they're not needed or prescribing things that are not appropriate for them," Nguyen said. "Sometimes I tell them something and they're not happy with it, but at least I told them. I can't make them do this, but I will tell them what will happen if they don't take care of an issue.

"But I want them to have their say. I think patients are more savvy today. They read things online or see them on TV, like Dr. Oz. There's more out there to read, and that's OK, but you have to make sure it's pertinent to you."

Owensboro'sLorell Crabtree said she hasn't "clicked" with some health care professionals, but became a patient of Nguyen's earlier this year because she liked his approach.

"The first time I went to see him, he said, 'Let's sit here and chat a minute,' " Crabtree said. "He asked me all kinds of questions. He's very personable and I felt I found somebody who was really interested in me. He didn't want to hurry up and get me in and out of the office."

Crabtree, 68, knew she had high cholesterol when she visited Nguyen but then found out she was also diabetic.

"He wanted to put me on medication and encouraged me to diet and exercise to get it under control," she said. "We talked about his recommendation because I didn't want to go on medication. He said I didn't have to take his recommendation.

"When he puts you on medication, he just doesn't keep you on it."

The collaborative approach, or a shared decision-making process, is when the physician and patient analyze situations together to reach a decision that both parties are satisfied with. However, health care officials say not all doctors are receptive to what patients have to say. Patients who want input should make a list of questions, get answers and make the points they want to make, even if it means bringing a supportive friend or family member to the physician's office.

Dr. Michael Scherm, who was named chief surgical officer at OHRH in 2013 after retiring from his surgical practice of 28 years, said he liked it when patients took a more active role in their care and were informed about their condition beforehand.

"Breast cancer, for example, can be very confusing for patients," he said. "There's surgery, chemotherapy, radiation therapy, reconstruction, reconstruction at the time of surgery or after surgery is over," he said.

"The Internet has a huge amount of information on it, some of it good and some of it inappropriate or inaccurate. But we would give patients websites and recommend that they read them and learn the different options, then come back and we'd talk about what they wanted to go through."

Scherm said there aren't a lot of surgical options for colon cancer. He could either open up a patient or do surgery laparoscopically.

"But if someone was adamant that they didn't want to have surgery for colon cancer, I would insist the patient get a second opinion simply because they needed to have surgery," he said.

When patients have a say in the treatment option, some prefer the one that is going to be less painful while others seek the quickest route a successful outcome, the physicians said.

"Some people want the most definitive outcome," Toler said. "They want whatever is going to be the most successful and not have to have surgery twice. Sometimes, that's not the smallest surgery. It's usually the most aggressive surgery, but that's changing a little with deductible plans. Patients are factoring in costs now when they may not have done that in the past."

Scherm said he never had patients ask about the cost of treatment, but rather, how much pain were they going to have to endure.

"That's why laparoscopic surgery has taken off in the last 15 to 20 years," he said.

Guidelines from health care agencies and insurance companies may also complicate medical treatment, Toler said.

"They're becoming more and more involved in the care of the patient," he said. "It's not just providing insurance for them, but providing plans for things that they want them to have done in trying to manage their health."

Scherm said he never practiced medicine on the East Coast, but has heard that patients there "are not as quick to agree with a doctor's recommendation."

"Maybe patients don't have as high regard for doctors, or maybe they think they know more than the doctor," he said. "At least in this area, patients still want to know what the doctor recommends."

Rich Suwanski, 270-691-7315, or [email protected].

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