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To make shared decision-making blossom, somebody needs to lead the discussion with carefully chosen words. I’m working on it.
Dr. Afshar is a third-year resident in the Department of Obstetrics and Gynecology at Cedars-Sinai Medical Center in Los Angeles, CA.
In the last week, I have had two patients look me straight in the eye and ask: “Doctor, what would you do if you were in my place?” The first patient was a 39-year-old G4P0 with IVF di-di twins at 22+0 weeks with preterm premature rupture of membranes. The second patient was a 69-year-old with recurrent Stage IIIC papillary serous ovarian carcinoma coming in for her third bowel obstruction in 12 months.
As a disclaimer, I am not one who is generally shy or short of opinion. And yes, I do have opinions in both patient cases. But that is not the real question the patients asked me. I remind myself that in that moment, patients do not really want to know what I would do; rather, they need help making informed decisions for themselves. These straightforward and raw conversations have become some of the most difficult challenges for me to tackle as a resident. Though residency trains us to answer questions confidentially and directly, these patient queries require a mastery of precise diction that, for physicians in training, sometimes is lost in the deluge of new information. I watch one of my brilliant attendings coordinate an eloquent dialogue of calculated word choice with continuous teach-back with her patients and it gives me something to strive for.
Medical school trains us to understand the underlying mechanisms of physiology and disease and the clinical years hone intellectual curiosity and skill. Sure, we have done our fair share of patient simulations and training in cultural competency; however, no curriculum addresses every hypothetical situation that we are faced with. I am still working hard to counsel patients strongly, fairly, and with well-chosen words. In short, I try to avoid verbal diarrhea.
A 2013 study in JAMA Internal Medicine highlighted the subtleties of word choice and meaning-the correlation between the words we choose and the actions patients take.1 It found that avoiding the term “cancer” in cases of ductal carcinoma in situ (DCIS) resulted in women choosing less-aggressive measures and avoiding surgical resection. The same correlation can be made with cervical intraepithelial neoplasia (CIN). It’s a delicate balance-convey urgency without fear; easy-to-digest information coupled with empowerment.
Take the good ol’ ob/gyn Pap test-our bread and butter (well, until the April 24, 2014 FDA statement about the HPV DNA test). The question remains: How do you counsel a patient with a positive HPV screen? Sure, I’ve memorized the CDC statistics-HPV is the most common sexually transmitted infection, with 79 million Americans who are currently infected and 14 million who will become infected each year.2 Most sexually active women and men get HPV at one point in their life. And yes, for the majority of them, it makes no difference. Aside from the 26-year-old who I will strongly recommend get a vaccine, I find myself sometimes struggling: “Your Pap test is abnormal” so . . . “HPV is the virus responsible for cervical cancer” and “Yes, this is a sexually transmitted disease . . ."
Undeniably, the ability to communicate is the conceptual framework for successful patient care. I recently listened to a webinar sponsored by the Association of Reproductive Health Professionals (ARHP) in which Dr. David Grimes (University of North Carolina, Chapel Hill) lectured about counseling in regards to patient decision making on hormonal contraception. The key points hold regardless of the topic and I think they are helpful when I try to translate data into tangible decision-making anecdotes for patients. These are some points that I aspire to use when discussing shared decision making with patients. In the words of Dr. Grimes:
1. Do NOT use numbers when comparing effectiveness or risk
- DO SAY, “DMPA is more effective than a condom.”
- DON’T SAY, “A condom is 85% effective and DMPA is 97% effective.”
2. When using absolute risk, use BOTH ratio and percentage, and do NOT shift denominator
- DO SAY, “3 out of 10 women develop nausea, or in other words, you have a 30% chance of developing nausea.”
- DO SAY, “3 out of 1,000 experience [symptom].”
- DON’T SAY, “1 out of 333 experience [symptom].”
3. Use absolute risk, NOT relative risk
- DO SAY, “20 in 100,000 women develop venous thromboembolism (VTE)”
- DON’T SAY, “If you take this medication, your chances of developing VTE will double.”
4. Use context
- DO SAY, “20 in 100,000 women develop VTE while on this medication, but 60 in 100,000 women develop VTE while pregnant.”
- DO SAY, “11.5 women per 100,000 die because of pregnancy, and 0.06 women per 100,000 die because of oral contraceptive pills.”
This is a job-in-progress. I hope I come out of residency able to counsel my patients like some of my mentors. I will provide factual and contextual information and empower patients to implement a solution with me-shared decision making. It is our job to be fully informed about the data, the risks, the benefits, and the evidence. To make shared decision-making blossom, somebody needs to lead the discussion with carefully chosen words. I’m working on it.
1. Omer ZB, Hwang ES, Esserman LJ, Howe R, Ozanne EM. Impact of ductal carcinoma in situ terminology on patient treatment preferences. JAMA Intern Med. 2013;173(19):1830–1831.
2. Centers for Disease Control and Prevention. Human Papillomavirus (HPV). http://www.cdc.gov/std/HPV/STDFact-HPV.htm. Accessed July 8, 2014.