Three Questions Patients Should Ask To Improve the Information They Receive
According to Shepherd et al , the following questions appear to be powerful catalysts for good information exchanges between clinicians and patients:
1. “What are my options?”
2. “What are the benefits and harms of each?”
3. “How likely are the benefits and harms?”
Let’s start with Shepherd’s cross-over trial using the three questions above. In order to make informed decisions and improve outcomes, patients need reliable information about benefits and risks of the various options. In this randomized cross-over trial, Shepherd et al. used two standardized patients with identical symptoms— one patient asked the three questions (and also about doing nothing if the physician did not mention this option), the other did not. The patient presented as an otherwise healthy divorced middle-aged female with one prior undiagnosed episode of depression and 3 months of worsening moderate symptoms of depression. Depression was chosen as the condition because evidence is available and patients express differences in preference for treatment. The authors found that the 3 questions were associated with greater provision of information and behavior supporting patient involvement without extending appointment time.
Stiggelbout et al. remind us that shared decision-making (SDM) should be routinely employed to ensure patient autonomy, beneficence (balancing risks and benefits), non-malfeasance (avoiding harm) and justice (patients frequently decline procedures when adequate information has been provided and this may result in improved sharing of limited resources). Pamphlets, videos, tools of various sorts may be employed to facilitate SDM. Tactics and tools that appear to increase SDM include—
- Creating awareness of equipoise (there is no best choice but a decision must be made—even if it is to do nothing);
- Presenting or encouraging patients to ask about options and benefits and risks of each option;
- Use of graphical displays to present risks;
- Use absolute risk information such as the number of similar patients/100 or number/1000 who will benefit*;
- Encouraging patients to pay attention to their preferences;
- Provide appropriate support to help patients make decisions—respect the patient’s preference about his or her role—independent, shared or delegated decision-making role.
*We would add that this information is only useful when also providing information that provides a more complete picture. To hear that one’s chance of benefiting from an intervention is 5 out of a hundred has a very different meaning depending upon the specific context:
- Scenario 1: Out of 100 patients, 10 taking drug A improved as compared to 5 taking placebo, versus—
- Scenario 2: Out of 100 patients, 90 taking drug A improved as compared to 95 taking placebo.
Examples of decision-aids are available from the following: http://shareddecisions.mayoclinic.org.
Delfini Comment: “Patient demand,” i.e., activating patients to voice their information needs, has been proposed as a method of improving healthcare consultations for several decades. In our experience, educational programs aimed at increasing the use of evidence-based information sharing with patients has been hampered by clinicians frequently not possessing accurate answers to the three questions studied here. The two studies discussed above [3,4] indicate that patient-mediated approaches may be at least part of the answer to improved clinical decision-making.
1. Shepherd HL et al. Three questions that patients can ask to improve the quality of information physicians give about treatment options: a cross-over trial. Patient Educ Couns. 2011 Sep;84(3):379-85. Epub 2011 Aug 9.PubMed PMID: 21831558.
2. Stiggelbout AM et al. Shared decision making: really putting patients at the centre of healthcare. BMJ. 2012 Jan 27;344:e256. doi: 10.1136/bmj.e256. PubMed PMID:22286508.
3. Bell RA et al. Encouraging patients with depressive symptoms to seek care: a mixed methods approach to message development. Patient Educ Couns. 2010 Feb;78(2):198-205. Epub 2009 Aug 11. PubMed PMID: 19674862.
4. Kravitz RL et al. Influence of patients’ requests for direct-to-consumer advertised antidepressants: a randomized controlled trial. JAMA. 2005 Apr 27;293(16):1995-2002. Erratum in: JAMA. 2005 Nov 16;294(19):2436. PubMed PMID: 15855433; PubMed Central PMCID: PMC3155410.