When I had a heart attack two years ago, I was taken immediately from the E.R. to the O.R. for emergency treatment for a left anterior descending coronary artery that turned out to be 99% blocked. But, overwhelmed and terrified, I knew nothing of what was about to happen to me, even though I have a vague memory of the cardiologist explaining something to me before I was taken upstairs. I could see his lips moving and I could hear sounds coming out of his mouth, but he could have been speaking Swahili. I don’t think I was capable of comprehension at the time. Everything I know about surviving what’s known as the “widowmaker” heart attack, I learned much, much later.
I’m not alone. A new study suggests that heart patients believe that their cardiac interventions have far greater benefits than they actually do.
The research, published in the journal Annals of Internal Medicine, found that over 80% of the 153 heart patients studied who had undergone angioplasty with stents implanted thought that the procedure would cut their odds of having a future heart attack. But about the same proportion of the 27 cardiologists who had either referred these patients for angioplasty or performed the procedure reported to researchers that they had told their patients that stents would do nothing more than simply relieve chest pain.
The Boston Globe calls this a “yawning disconnect between what doctors say and what patients hear”.
This disconnect extends to other types of medical treatment as well, resulting in patient confusion and even overuse of some procedures. Cancer patients, for example, often believe that chemotherapy will destroy a tumour, counting on a cure that medical evidence does not promise at all.
Dr. Henry H. Ting from Mayo Clinic told a HealthDay interviewer that he was not surprised by the study findings. He pointed to a previous Mayo Clinic study that had found 80% of patients signed consent forms they had not even read, and did not actually know the benefits or risks of the treatment they were having.
Dr. Ting, who conducts research on informed consent, said the problem of patient understanding is common in many areas of medicine.
“We [doctors] don’t do a good job of knowledge transfer in a way that patients and family members can understand. Graphs and charts are not going to work for many of our patients.”
Other experts also blame flaws in the informed consent process for this communication gap. Dr. Alicia Fernandez of the University of California San Francisco told Cardiovascular Business News:
“It’s important to incorporate decision aids or educational material so that patients at least get a brochure outlining the risks, the expected benefits and others that are not expected benefits.”
One reason for patients’ misunderstanding is the common belief, cited in the recent study, that if a treatment is offered, it must have curative benefits.
And apparently some cardiologists are equally confused.
According to the study’s authors, for example, fewer than one-third (31%) of those who agreed to undergo elective cardiac catheterization actually had the type of activity-limiting angina pain that angioplasty might even be expected to ease – an appalling statistic which may make you wonder why the procedure was done on two-thirds of these people in the first place. (See also: Cardiologists Accused Of Implanting Cardiac Stents That Weren’t Needed.)
In fact, the study’s authors noted that treatment benefits can often be achieved with heart medications alone.
Nevertheless, almost three-quarters of all the patients studied still believed that if they didn’t undergo angioplasty, they would suffer a heart attack within the next five years.
Where are they getting this idea?
Study authors admit that they were not present during “informed consent” discussions between patient and doctor, and so had to rely instead on what cardiologists told them they had said to patients.
Only patients who are actually in danger of having an imminent heart attack can expect angioplasty or stent implantation to reduce risk of future heart attacks and death, according to 2007 research cited in the study.
But cardiologist Dr. Marc J. Schweiger of Tufts University School of Medicine (the senior author of this study) told The Boston Globe:
“This is not a cardiology issue; this is a medical issue.
“I suspect if you looked at any procedure you would find the same results. Doctors think they explain [them] to patients, and patients for variety of reasons are misinformed.”
Dr. Richard Frankel, a Regenstrief Institute research scientist at the Indiana University School of Medicine, offers this observation on the classic doctor/patient miscommunication problem:
“We don’t assume when a pilot and an air traffic controller converse that they have understood each other until there is an affirmation of understanding. That acknowledgement is lacking in most patient-physician encounters.”
Dr. Frankel, who studies ways to improve the doctor-patient relationship, is currently investigating how behavioural changes by both doctors and patients impact medical care. He adds:
“From previous work, including a well-regarded 1999 study from the University of Washington, we know that doctors ask patients whether they understand what was just discussed less than 2% of the time.
“Doctors should be trained to routinely check for understanding to ensure that there is neither miscommunication nor mismatch between what the patient wants and what doctors assume the patient wants.”
Patients are not to blame for that miscommunication about cardiac stents, says Dr. Michael Pignone, a medical editor for the Boston-based Foundation for Informed Medical Decision Making.
As a heart attack survivor and now a frequent flyer in our health care system, I tend to agree with Dr. Pignone.
For starters, when two people who are on equal footing are communicating calmly using a similar knowledge base, we might expect a reasonable level of mutual comprehension. Two auto mechanics can talk shop together trusting that they absolutely understand each other. Ditto for two oceanographers. Two accountants. Two computer programmers.
But just try putting one of those two people in a drafty hospital gown, lying confused and vulnerable on an E.R. gurney while suffering distressing physical symptoms. Put the other person in a starched white coat, standing overhead coolly rattling off a jargon-filled explanation of what may or may not happen next. It’s a tragic recipe for miscommunication.
Should it be up to the person in the drafty gown to ensure that doctor-patient communication is accurate or effective during an emotionally overwhelming medical event?
Doctor-patient communication has been the life’s work of the University of Toronto’s Dr. Wendy Levinson. Her landmark research comparing doctors who had never been sued for medical malpractice with doctors who had been sued at least twice offers valuable insights on why doctors get sued.
When comparing the respective bedside manner of each group, Dr. Levinson reported no difference in the amount or quality of information doctors gave their patients. For example, the never-sued doctors didn’t provide more details about medication or the patient’s condition.
The difference was entirely in how they talked to their patients. See also: Why Doctors Get Sued.
Dr. Levinson adds that, although her colleagues are often more focused on their medicine than on their communication skills, she knows consumers can certainly relate to the need to enhance doctor-patient communication.
“At cocktail parties, when I tell other doctors what I do, they’re not really interested. But if I tell patients, they ALL have a story to tell.”
- the Fierce Practice Management report called Most Heart Patients Confused About Stent Benefits.
- the Cardiovascular Business article called Doc, Patient Perceptions Differ on PCI, Consent Needs Overhaul
- the Heart Sisters article called Your Health Care Decisions: Don’t Worry Your Pretty Little Head Over Them
- The Ethical Nag articles called Cardiologists Accused Of Implanting Cardiac Stents That Weren’t Needed and Stent-Happy Docs on Notice in Maryland Health Care Fraud Debate
© 2011 Carolyn Thomas – Heart Sisters – www.myheartsisters.org