Shared decision-making is a new paradigm in health care that empowers patients to make their own decisions regarding screening, treatment, and care. Unlike former models in which patients largely deferred decision making to providers and physicians, shared decision making educates and empowers patients to make treatment decisions that incorporate their own unique values and needs.1 This shift highlights the importance of understanding what factors drive decision making by patients.
The most obvious factors driving patient decision making are the “rational” ones that might be considered in a cost-benefit analysis. Considerations often include expense of treatment, indirect costs such as lost wages, likelihood of survival, probable complications, and quality of life, among others. But patients do not typically undertake rational economic analyses when making health care decisions. One reason is that outcomes data are notoriously difficult to obtain, making many relevant statistics only available to very enterprising patients. Furthermore, the difficult and complex nature of these medical decisions can easily overwhelm patients. There is a large amount of scientific evidence to be reviewed and analyses to be done in order to arrive at the optimal treatment. With so much to consider, many patients may feel they lack the necessary expertise and may simply leave health care decisions to their physicians.2
The most important decision making factors may actually be psychological or behavioral-economic in nature. In an example from oncology, a study compared the views of two groups of women. The first group was asked to estimate their lifetime risk of developing breast cancer (their mean estimate was 41%) and then informed of their actual lifetime risk (13%). The second group was told their actual lifetime risk of developing breast cancer up front. The first group reported feeling relieved after learning about the 13% figure, which was considerably lower than their initial estimate, while the second group did not feel the same sense of relief, and reported instead that the 13% figure was about what they had expected.3 This example of “hindsight bias” has significant medical implications: the first group may be less likely to receive mammograms because of the relief they felt after learning that their actual risk of developing breast cancer is lower than they initially expected. Empowering patients to not only choose, but to believe in their treatment regimen improves adherence and outcomes.2 Thus, physicians should be aware of the psychological framing of their recommendations if they are to be effective in educating patients.
It is imperative that anesthesia professionals take into account both rational and psychological factors when planning anesthesia management. Patient health and finances, anesthesia practices, and society at large depend on rational decision making. However, rational planning is not effective until it incorporates patient psychology and insights from behavioral economics. Anesthesiology professionals play an especially important role in decision making because of their role in managing patient pain and comfort. Pain is a powerful driver of patient psychology, and the pain a patient anticipates experiencing from a course of treatment is sometimes the single greatest factor influencing a patient’s decision-making. This calls for anesthesia professionals to be leaders in the movement towards shared decision making. Their expertise is needed to design decision aids that effectively guide patients in matters concerning pain management, and in planning efficient anesthesia services. For example, there is pressure placed on anesthesia providers to use lower-cost anesthetic drugs, even though drug expenses are small compared to labor costs in most anesthesia practices.4 Anesthesia professionals are well-positioned to advocate for solutions that improve practice efficiency while preserving patient comfort and safety, such as better scheduling of anesthesia services and staff. The continued engagement of anesthesia providers at the forefront of patient care and anesthesia management is critical for advancing shared decision making and improving outcomes.
- Lee, Emily O. and Ezekiel J. Emanuel. 2013. “Shared Decision Making to Improve Care and Reduce Costs.” The New England Journal of Medicine 368, no. 1: 6-8.
- Landro, Laura. 2017. “How to Get Patients to Take More Control of Their Medical Decisions.” The Wall Street Journal, February 28, 2017. https://www.wsj.com/articles/how-to-get-patients-to-take-more-control-of-their-medical-decisions-1488164941.
- Ubel, Peter A. 2010. “Beyond Costs and Benefits: Understanding How Patients Make Health Care Decisions.” The Oncologist 15, suppl. 1: 5-10.
- Watcha, Mehernoor F. and Paul F. White. 1997. “Economics of Anesthesia Practice.” Anesthesiology 86, no. 5: 1170-96.