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Presenting options to patients: Menu approach good for patients and physicians


INDIANAPOLIS — A significant proportion of medical treatment decisions, perhaps the majority, are not clear-cut. Which is better for a specific patient — medication or surgery, medication or talk therapy, or even no treatment? If medication, which class of drugs? If surgery, what type of surgery?

Presenting and discussing a menu of treatment options is good for both the patient and the physician according to Regenstrief Institute and VA Center for Health Communication and Information investigator Kurt Kroenke, M.D., writing in a commentary in the Sept. 28 issue of JAMA Internal Medicine.

“If a patient has reservations about what the physician is recommending, the patient should ask for alternatives,” said Dr. Kroenke, Chancellor’s Professor and professor of medicine at Indiana University School of Medicine. “While physicians face increasing time pressures, working with the patient to select the best option is well worth the time in terms of patient compliance and ultimately health improvement.

“Less than 10 percent of decisions made in outpatient encounters meet the minimum standards for informed decision making, and only 40 percent of palliative care decisions are congruent with patient preferences,” Dr. Kroenke wrote in the commentary, “The Role of Decision Aids in Depression Care.”

A menu of reasonable treatment options exists for many conditions — depression, cancer and numerous others — frequently seen by primary care physicians.

“Physicians often present only a single treatment option when others exist, without outlining those possibilities,” Dr. Kroenke said. “Through dialogue with the patient it may become apparent that the best alternative from the patient’s viewpoint may not be what the physician customarily recommends. A partnership approach that includes patient preference can make a real difference.

“The doctor should discuss what’s behind curtain number one, curtain number two and curtain number three, explaining the pluses and minuses of each choice. Because of time pressures during busy clinical visits, easy-to-use decision aids may help facilitate patient choices.”

The commentary noted, “One wonders how often in a busy clinical setting, when there is a choice among medications to treat a disease, the clinician actually discusses the pros and cons of different options. It may be less important for short-term use of drugs to treat acute conditions. However, for medications prescribed for chronic use, informed patient input may be especially desirable.

“Decision aids could either be used routinely or targeted towards certain patients based upon their decision-making preference, sociodemographic characteristics, and history of medication intolerance or prior treatment failures. Moreover, chronic conditions often require treatment changes over time and cumulative education about different therapeutic options might make the patient a more informed partner not only cross-sectionally (i.e., for initial treatment decisions) but also longitudinally (i.e., for subsequent modifications in therapy).”

Dr. Kroenke is a primary care physician and an internationally respected expert in medical symptoms. He is the co-developer of the PHQ-9 depression screening tool — known as the “blood pressure cuff for depression” — and the GAD-7 anxiety screener. He is former president of the Society of General Internal Medicine and of the Association of Clinical Research Training.