Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Why shared decision making is difficult in practice

Davis Liu, MD
Physician
June 27, 2013
Share
Tweet
Share

As a practicing primary care doctor, I very much believe that better care is when patients are engaged and share decision making with their doctor. Though in the past doctors treated patients in a paternalistic manner, my generation of doctors has been taught to uphold a balanced doctor-patient relationship and partnership. This change in balance of power has accelerated with the ease and availability of information via the internet. More patients not only are asking about diagnoses and treatments, but correctly self-diagnosing. They merely come by to check in with me to make sure they got it right and to clarify the treatment options.

Overall, this is better patient care.

However, over the past few years a trend has gotten more momentum. As health care becomes increasingly unaffordable, many believe quality and costs would improve if we treated health care like other markets where consumers drive health care. If only patients were even more engaged in researching medical tests, procedures, providers, and pricing, like they do when buying a television or car would health care be affordable.

If only that were true.

There are limits to this trend. Though everything I diagnose and evaluate can be researched online, there is a difference between knowledge and wisdom. Even understanding costs with price transparency does not mean people will act differently. It is possible that consumer driven health care will fail to live up to its expectations? These two facts alone make the claims of consumer driven health care dubious.

As an example, I a reminded of my recent visit to my car dealer. Minutes before driving to an important meeting, my 16-year-old BMW failed to start. All the dashboard indicators and dials flashed wildly. My guess was that the battery died. It was fine just 4 hours ago.

I called AAA. They jumped the battery. The engine roared to life again. Since it was only good until I turned off the engine, I immediately drove to my car dealership, without an appointment, to get a new battery. It turns out that AAA battery service does not carry the battery needed to fix the problem.

Now I know this car dealership very well. My car has been under their care for about a decade. Every time the service required indicator comes on is when I see them. Each maintenance service is dutifully recorded in their electronic system. As far as I knew I was up to date on everything.

Since they were going to change the battery, would they also mind fixing the fog light? It had been broken for a while, but I hadn’t bothered to deal with it. My wife, however, discovered it was broken recently and insisted I ask them to address the problem. If it was up to me, I would have left it alone.

So far, so good. This story isn’t much different than a patient suffering from an unexpected acute injury, which needs immediate medical attention.  He sees his doctor the same day. Patient hasn’t needed care for a while. Since he is now at the doctor’s office, there was this other issue that has been a problem for a while; might the doctor evaluate it too?

My car dealer service advisor returns. The battery and the fog light are not available until the next day. It will take him at least until tomorrow before the car can be returned. Here was the price. Evidently, BMW batteries are not cheap. It isn’t like I could go compare battery prices and drive around town to get it installed. I would have to jump start the car each time to make it happen.

As I give the verbal consent to being the process, my service advisor also tells me that there were two other issues. As the mechanic was evaluating my car, he noticed that hose that contains steering wheel fluid was leaking. It was not clear how long that was occurring. Also, since they noticed I was due for a tire rotation and brake inspection, he did that as well. The rear brake pads were just 3 mm and would need replacement. What did I want to do?

Now, what am I supposed to do? I could ask how much it would cost, but the cost must be relative to what? Is it based on how likely I felt going without repair would or would not be risky? It is based on how much money I had available in my bank account? It is based on my belief that my car dealer is trying to get more money out of me? Is it possible other auto repair shops might have better prices?

Though I could shop around, I wouldn’t know what to make of a higher or lower price. Is a lower price better than a higher one? How am I supposed to tell the difference? How do I judge quality? I’m not a mechanic. I don’t have a friend who is a mechanic.

ADVERTISEMENT

Increasingly, patients are asked to shop around for MRI tests, negotiate with doctors for tests or procedures because they are responsible more in sharing costs. Can they judge quality or value? Is it possible the more expensive option actually has more value?

After judging the value of cost and trying to determine if I’m getting a “fair” price, I now need to prioritize which repair to do. It’s not like I planned for the car battery to die. That needs to be addressed. Perhaps I could skip the foglight repair and face the wrath of my wife. I certainly didn’t know about the steering hose leak. Steering seems ok. What would happen if the leak got bigger? Would I simply need to pull on the steering wheel harder? The brakes? The car stops fine. Are the 3 mm brake pad lining thickness really a problem? What if I waited on those? How much longer can I wait? What does 3 mm mean in the grand scheme of things? It’s better than 2 mm but is it 50 percent better? No wonder patients feel uncomfortable interpreting a hemoglobin (measure of red cells) count. What does 9 mean when the normal is 12.5 and is that a little worse or a lot worse than 11 versus 7?

He shows me the prices of the repairs. He tells me it will take an additional day on top of the day already spent to order the battery.

So I ask the service advisor, what should I to do?

It’s your choice. I would recommend you address them as soon as possible.

Ah … shared decision making.

Now, I suppose I could go home after the battery repair and research what is considered the appropriate brake pad thickness for a 1997 BMW 328i 4 door coupe. I could have him walk me to the car and so me the extent of the leak in the steering hose. I could even shop around various auto shops and ask them what they thought. Perhaps I didn’t need any of these repairs. After all, isn’t this the behavior that consumers are supposed to display? I shouldn’t take what my mechanic says as gospel. He could be wrong and selling me parts and services, which are unnecessary. Even if the repairs were needed, I might even find a better price even though I would no idea how to judge which mechanic performed better or worse than my car dealer’s mechanic. I’ve already been with the car dealer for many years. They do sell BMWs so surely they know what they are doing.

So what would you do?

Do you take MasterCard?

There is some evidence already that the costs savings touted by consumer driven health care are not occurring. Recent articles noted that “increasing healthcare cost sharing does little to reduce overall healthcare costs or make it more efficient” and that patients more involved in their medical care, “may also wind up with longer hospital stays and higher bills than their peers who leave the decision making up to their doctors.” For health care to be better quality, more accessible, and more affordable we should welcome all new ideas but also realize the limitations of them.

After all, if health care’s problems were so easy to solve, wouldn’t they have been solved already?

Davis Liu is a family physician who blogs at Saving Money and Surviving the Healthcare Crisis and is the author of The Thrifty Patient – Vital Insider Tips for Saving Money and Staying Healthy and Stay Healthy, Live Longer, Spend Wisely.

Prev

Family physicians are more comfortable with uncertainty

June 27, 2013 Kevin 7
…
Next

What being a primary care patient has to do with home renovation

June 28, 2013 Kevin 2
…

Tagged as: Primary Care

Post navigation

< Previous Post
Family physicians are more comfortable with uncertainty
Next Post >
What being a primary care patient has to do with home renovation

ADVERTISEMENT

More by Davis Liu, MD

  • The mission to make health care equitable and accessible for all

    Davis Liu, MD
  • How to close the leadership challenge and end this COVID chapter

    Davis Liu, MD
  • What’s wrong with health care, and do we have the will to change?

    Davis Liu, MD

More in Physician

  • Why the doctor-patient relationship needs a redesign

    Alexandra Novitsky, MD
  • Imposter syndrome is not a personal failing

    Jessie Mahoney, MD
  • How functional medicine fills the gaps left by conventional care

    Sally Daganzo, MD
  • A step‑by‑step guide to crafting meaningful research questions

    Julian Gendreau, MD
  • How restrictive opioid policies worsen the crisis

    Kayvan Haddadan, MD
  • The dying man who gave me flowers changed how I see care

    Augusta Uwah, MD
  • Most Popular

  • Past Week

    • Health equity in Inland Southern California requires urgent action

      Vishruth Nagam | Policy
    • Could antibiotics beat heart disease where statins failed?

      Larry Kaskel, MD | Conditions
    • How restrictive opioid policies worsen the crisis

      Kayvan Haddadan, MD | Physician
    • Why palliative care is more than just end-of-life support

      Dr. Vishal Parackal | Conditions
    • When life makes you depend on Depends

      Francisco M. Torres, MD | Physician
    • Guilty until proven innocent? My experience with a state medical board.

      Jeffrey Hatef, Jr., MD | Physician
  • Past 6 Months

    • Why transgender health care needs urgent reform and inclusive practices

      Angela Rodriguez, MD | Conditions
    • COVID-19 was real: a doctor’s frontline account

      Randall S. Fong, MD | Conditions
    • Why primary care doctors are drowning in debt despite saving lives

      John Wei, MD | Physician
    • New student loan caps could shut low-income students out of medicine

      Tom Phan, MD | Physician
    • Why pain doctors face unfair scrutiny and harsh penalties in California

      Kayvan Haddadan, MD | Physician
    • mRNA post vaccination syndrome: Is it real?

      Harry Oken, MD | Conditions
  • Recent Posts

    • Why the doctor-patient relationship needs a redesign

      Alexandra Novitsky, MD | Physician
    • Health equity in Inland Southern California requires urgent action

      Vishruth Nagam | Policy
    • Imposter syndrome is not a personal failing

      Jessie Mahoney, MD | Physician
    • Why sleep must become a central pillar in modern health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • How early care saved my life from silent kidney disease

      Charlie Cloninger | Conditions
    • How functional medicine fills the gaps left by conventional care

      Sally Daganzo, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 6 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Health equity in Inland Southern California requires urgent action

      Vishruth Nagam | Policy
    • Could antibiotics beat heart disease where statins failed?

      Larry Kaskel, MD | Conditions
    • How restrictive opioid policies worsen the crisis

      Kayvan Haddadan, MD | Physician
    • Why palliative care is more than just end-of-life support

      Dr. Vishal Parackal | Conditions
    • When life makes you depend on Depends

      Francisco M. Torres, MD | Physician
    • Guilty until proven innocent? My experience with a state medical board.

      Jeffrey Hatef, Jr., MD | Physician
  • Past 6 Months

    • Why transgender health care needs urgent reform and inclusive practices

      Angela Rodriguez, MD | Conditions
    • COVID-19 was real: a doctor’s frontline account

      Randall S. Fong, MD | Conditions
    • Why primary care doctors are drowning in debt despite saving lives

      John Wei, MD | Physician
    • New student loan caps could shut low-income students out of medicine

      Tom Phan, MD | Physician
    • Why pain doctors face unfair scrutiny and harsh penalties in California

      Kayvan Haddadan, MD | Physician
    • mRNA post vaccination syndrome: Is it real?

      Harry Oken, MD | Conditions
  • Recent Posts

    • Why the doctor-patient relationship needs a redesign

      Alexandra Novitsky, MD | Physician
    • Health equity in Inland Southern California requires urgent action

      Vishruth Nagam | Policy
    • Imposter syndrome is not a personal failing

      Jessie Mahoney, MD | Physician
    • Why sleep must become a central pillar in modern health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • How early care saved my life from silent kidney disease

      Charlie Cloninger | Conditions
    • How functional medicine fills the gaps left by conventional care

      Sally Daganzo, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Why shared decision making is difficult in practice
6 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...