What the doctor says, and what the patient hears and understands, are sometimes not the same thing at all.
A new study, published in the Annals of Internal Medicine, examines this communication gap by focusing on a specific procedure: percutaneous coronary intervention for stable coronary artery disease – or, in layperson’s terms, threading a catheter and stentÂ into one or more of the major blood vessels of the heart to reduce blockage.
It’s a fairly common procedure for people with heart disease. Often it can reduce the chest pain that’s associated with angina – but it doesn’t necessarily reduce the risk of a future heart attack, and it’s no guarantee the patient won’t have a fatal heart attack at some point. These last points aren’t always grasped by patients, however, according to the authors of the Annals study.
The authors surveyed 153 patients who had consented to undergoing percutaneous coronary intervention if other tests showed blocked blood vessels. They also surveyed 27 cardiologists who had either referred the patient or performed the procedure.
What they found was thatÂ 88 percentÂ of the patients mistakenly thought the procedure would reduce their risk of heart attack, and 82 percent thought it would reduce their risk of dying from a heart attack. Among the cardiologists, however, the majority believed these patients would only see relief from angina.
It’s hard to draw any firm conclusions from this study. It was quite small, involving a single hospital, fewer than 30 cardiologists and only slightly more than 150 patients. The researchers didn’t have access to the amount or quality of the discussion the cardiologists had with their patients before the procedure, nor did they measure what the patients’ beliefs may have been before and after the discussion to give informed consent.
Nevertheless, it’s an interestingÂ study for how it reveals the differences in perception that often exist between patients and clinicians. ThereÂ could beÂ two possible ways of looking at the findings: Either doctors aren’t very good communicators, or patients aren’t very good at listening or understanding what they’re told, or some combination of all three. I suspect, however, that what this study has uncovered is more subtle than this.
There’s an inevitable knowledge gap between patients and physicians. Sometimes it leads physicians to assume that what’s obvious to them – in this case, that PCI has little if any effect on heart attack risk – is equally obvious to the patient. It’s not a safe assumption to make, but it often goes unchallenged. It might not even occur to the doctorÂ to ask patients to clarify their understanding of the benefits of the procedure they’re about to undergo. And sometimes, of course, patients hear what they want to hear, even when what they think they heard isn’t what was actually said.
The other issue is the high expectations to which we in the United States are acculturated.Â The publicÂ frequently overestimates what medicine can deliver. I’d be one of the first to admit the media have often been complicit in this by playing up the benefits and not being clear enough about the limitations. Physicians are usually much more realistic but it’s not always a message that’s heard.
A companion piece to the Annals study makes another important point: The informed consent process usually focuses on the risksÂ of a prescription drug or medical procedure or treatment. Perhaps the process also needs to focus more on the benefits so patients’ expectations are better aligned with reality.
Communication is always a tricky thing but neverÂ more so than in health care, where the stakes areÂ high and the information is complex. All too often, even when both parties are doing their best, the message can easily get lost in translation.
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