As “informed consent” has become just a formality, it is up to the individual doctor to really give the patient a “informed choice” if one exists. Informed choice is the real informal discussion to actually make the shared healthcare decision based on patient’s best interest. The choice can be as simple as choosing between two blood pressure pills, a new pill with a high co-pay and slightly better side effect profile or a time tested classic pill available on the Walmart $4 generic list. Currently, this decision is mostly based on the style and personality of the doctor. But, I believe that a decision like that should be based on the patient’s personality and beliefs.

At other times, the decision can be between a cardiac cath and medical management of heart disease. Sadly, in such cases, informed consent only comes onto play when the decision has been made to get the cardiac cath. It takes a lot of integrity on the part of the cardiologist to truly give a “informed choice” between the two options if you just look at the process from a pure consumer point of view. Can you imagine a car salesman giving impartial advice to help the costumer decide if he really needs a new car?

There are times when one approach is clearly better than the other but there are also times when it again comes down to the doctor’s personal preference and practice style where it should have been the patient’s preference and personality.

Personally, I think this problem needs a change in attitude of both parties. We need more patients to demand a clear choice when it exists. They have to understand that sometimes it is choice between doing something and not doing anything at all. Patient leaders here can help them know their choices. On the other hand, doctors need to understand that the choices are for the patients, not for themselves.

Regarding cases in which the patient refuses to participate in decision making I think it becomes incumbent on the provider to tease out the reasons for this (apparent) reluctance. Some reasons for refusal to participate in decision making may be addressed as separate issues to bring the patient into the process.

I’m thinking of educational background, societal expectations, language barriers and the structure of the medical visit (ie patient feels rushed and does not think that questions or discussion would be welcome).

In the past, such patients were almost a “bonus” to clinicians because they were less labor intensive, they moved the schedule along and went along with what was being proposed.

My suspicion is that the compliance by patients who were not actively involved in decision-making was less than optimal.

In an environment where ePatients are increasingly advocating to become participants in their own care, it will be important for care providers to get a grasp on whether or not all of our patients are participating in care decisions in a way that assures optimal outcomes. We certainly do not want to create an “ePatient divide” or a multitiered system of health information.

Thanks again, Howard.