'Informed Decision' May Irk Surgeons as It Cuts Costs, Improves Quality

Cheryl Clark, for HealthLeaders Media , August 16, 2012

"Eventually you could die"

Makary confesses that as a trainee, he engaged in a practice he called "patient manipulation" as a survival mechanism.

"I was under pressure to get [patients] to sign surgical consents. If a patient asked, 'What if I don't have this done?' I would cut right to the chase and say, 'Eventually you could die.' That was a phrase that circulated a lot among residents."

The idea to get patients to consider their own unique health status before making a decision is, in part, the brainchild of James Weinstein, DO, a spine surgeon and former head of the Dartmouth Institute. He is now President and CEO of Dartmouth-Hitchcock healthcare system. 

Just in his field of spine surgery, he says, "we know that in shared decision-making models, when patients are given good information, 30% choose not to have surgery."

Some versions of the concept have been rolled out at Dartmouth for a variety of orthopedic procedures, Weinstein says. All take the surgeon out of the decision-making equation because of obvious conflicts of interest they may have, conscious or unconscious.

Decisions about non-emergent surgeries "should be made at the primary care doctor level. That's what we at Dartmouth do," he says.

Naturally, the idea will get the best reception in healthcare systems with salaried surgeons, like Dartmouth-Hitchcock or Makary's Johns Hopkins.

Several systems, like Intermountain and the Mayo Clinic, are rolling out versions of this model soon. At Mayo Clinic, it's being adopted to help patients choose how to choose medications for their diabetes.

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9 comments on "'Informed Decision' May Irk Surgeons as It Cuts Costs"

Marshall Steele MD (8/20/2012 at 9:32 AM)
One of the biggest issues we have in medicine is that in my experience only 2% of surgeons collect and aggregate their patient rpeorted outcomes pre and post operatively. They can't accurately provide informed consent based on their own experiences? Our data base shows there is considerable variation amongst providers doing the same procedures. Quoting the literature is not the same as quoting your results. Until collecting and providing your own data to patients becomes part of the medical culture "second opinions" and "informed consent" will be less than accurate. Technology has made this much easier and affordable to accomplish.

M Makary (8/18/2012 at 7:32 PM)
Excellent article

Phillip (8/18/2012 at 12:00 PM)
The concept may be good but the process proposed is inherently flawed. In general, the Physician ordering a test (other than an x ray) should be a physician who is trained to interpret the test and trained to provide appropriate treatment options, either non-surgical or surgical. That physician is usually a specialist This "Informed Decision" process will not "irk" surgeons providing it does not add unnecessary bureaucracy which increases cost, and does not delay necessary treatment which is urgently needed in some cases. Informed patients are a surgeons ally not adversary.




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