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Making Choice an Option

You just go for regular exams and let the doctor keep track of any changes. Why don't you ask the doctor what he thinks about watchful waiting?"

Two weeks later, Rubin went back to his urologist, explained what his wife had said, and asked, "Would watchful waiting be a good idea for me?"

His doctor smiled broadly. "I think watchful waiting would be an excellent idea."

When Rubin got home and told his wife, she shook her head. "Whatever happened to 'If you were my father . . . ?'"

"I don't know," said Rubin. "Maybe I just didn't listen well enough the first time."

Choice, not just consent
Joe Rubin's story illustrates why "informed consent" is such a slippery idea. While doctors try to give patients the information they need to decide how to treat diseases like early-stage prostate cancer, it is extraordinarily difficult for most patients to absorb all the facts about their disease, understand all the treatment options, weigh their differing risks and benefits, and determine what is right for them. For some conditions, such as a broken hip, there's no decision to be made—there's a single, agreed-upon course of treatment. But for an increasing number of conditions—ranging from back pain to breast cancer—there are several acceptable options. Some doctors favor one, some another.

Little wonder, then, that most patients ask their doctors: "What would you do?" In many ways, this reliance on the doctor's expertise makes sense: the physician knows more about the disease and has seen many patients try the various options.

Nevertheless, when asking "What would you do?" the patient is asking for the doctor's personal preference. Would a doctor with prostate cancer like Joe Rubin's choose radiation and risk

Spencer, right, started by filling out an intake questionnaire on a touch-screen computer at the shared decision-making center. Here, clinical secretary Deborah Woodward goes over the results with Spencer and her son, Winston.

"[It] gave me a warm feeling, like somebody out there really cares."

—Feedback about shared decision-making at DHMC

impotence—or opt for watchful waiting and take a chance that the cancer won't progress? If he decides on watchful waiting, would he be able to put the cancer out of his mind—or would he feel a sword hanging over his head?

But the answers to these questions aren't universal. They depend on an individual's temperament, priorities, values, and personal situation. That's why DHMC opened its Center for Shared Decision Making in 1999—to help patients sort out what's important to them when deciding whether to choose radiation or surgery, whether to undergo PSA screening, whether to try a second chemotherapy regimen for ovarian cancer.

Traditionally, patients who choose an elective procedure provide "informed consent" by signing a document detailing all the things that might go wrong during

the treatment. What's different about Dartmouth's Center for Shared Decision Making is that it goes beyond just offering more information—it provides patients with an array of tools andmaterials to help them truly understand their treatment options so they can make a real choice.

As the discussion about U.S. health-care reform heats up, Dartmouth's shared decision-making center—the first in the nation—is stirring interest as a potential model for hospitals nationwide. In August, Senator Hillary Clinton spoke at DHMC as part of a series of appearances by the major presidential candidates. In her talk, she singled out Dartmouth's shared decision-making program for praise, noting that it gets high marks from patients. And in a press release detailing her proposals for reform, Senator Clinton said she'd like to see the federal government invest $25 million to encourage the development of similar programs elsewhere.

No right answer
Shared decision-making means that both the clinician and the patient must face up

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