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Making Choice an Option

lumpectomies. To argue that patients' preferences drove those decisions, one would have to believe that women in Elyria placed a far higher value on preserving their breasts than women in Rapid City—an inherently unlikely proposition.

More likely, women in each region were following their doctors' druthers. And indeed, when an investigative reporter went to Rapid City, she discovered that the physician who performed nearly all of the breast surgery in the area was a strong advocate of mastectomy—and did not offer his patients any other option.

Today that one-right-way mindset is changing. Caregivers are much quicker to admit to the uncertainties inherent in medicine—and to the importance of the patient's own preferences in making medical decisions. Or, as Dr. Annette O'Connor, research chair of the Ottawa Health Decision Centre and a visiting professor at DMS, puts it: "Every patient should get what they need—and no less, and what they want—and no more."

Progress, despite obstacles
Nevertheless, some doctors still resist the idea of relinquishing their authority. And it's not just older physicians who object, says Dr. Robert McNutt, a professor at Chicago's Rush University and chair of medical informatics and patient safety research at Rush University Medical Center.

When McNutt tackles the subject in his classes, he told the Associated Press in 2005, "the students get up and scream at me: 'If this is true, why am I going to medical school?'"

Some physicians grouse that they are not reimbursed for the time they spend talking to patients about making decisions. "Doctors ask: 'Why should I do this—and who is going to pay for it?' " Dartmouth's Weinstein reports. Moreover, "a lot of physicians believe that they are already doing everything that we do at the [shared

Next, with her son, Spencer watched a video on surgical options for early stage breast cancer. Patients can take the video home if they prefer. (Spencer had actually had her surgery by the time these photos were taken. She agreed to pose for them because of her gratitude for the care she got.)

"I had changed my mind by the end of the video."

—Feedback about shared decision-making at DHMC

decision-making] center. They say they tell patients all about risks and benefits.

"And I say, 'You can't possibly be—this isn't a five- or ten-minute discussion.'"

Too often, physicians "seek informed consent simply by presenting a scenario along the lines of 'here's what we have to do and why,'" observes Dr. Jerome Hoffman of the University of California at Los Angeles. He was the lead author of an article on informed decision-making published in the journal PloS Medicine last year. "This may or may not be accompanied by a briefmention of the possible risks of the proposed strategy," he says, "and in rare cases even by a very brief mention of potential alternatives—although this last element would typically be followed by a description of

why such alternatives are not really reasonable."

By contrast, Weinstein explains, true shared decision-making is a process by which the doctor shares any relevant information that he or she has about treatment options and their risks and benefits, while the patient shares any relevant personal information that might make one treatment or side effect more or less tolerable than others. "Then the physician helps the patient sort out what's best for him or her," Weinstein says.

The goal, he concludes, is to move medicine beyond informed consent—which means agreeing to what the doctor proposes—to informed choice—an active choice based on the patient's own hopes and fears.

Despite resistance to the concept, shared decision-making is reaching a tipping point, its advocates say. Dartmouth-Hitchcock is no longer alone in having such a center. In Massachusetts, Mass

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