Whose Choice is it Anyway?

At #PCP15, I listened to a symposium on how physicians communicate risk to patients. It reminded me of a recent post I had written on scaring patients. There was a patient on the sympo panel. She talked about surviving breast cancer and how when her surgeon sent her to an oncologist, the oncologist began writing down a chemotherapy regimen without even asking her if she wanted chemo or not.

I thought about the patients with diabetes I see at my clinic. These patients have multiple drugs, not only for diabetes but also for hypertension, high cholesterol, nerve problems etc. When the blood sugar is not controlled, I have to discuss either increasing the dose or frequency of the diabetes medication or adding a new one. The most common questions I get when I want to add another drug are –

• Will it damage my liver?
• Will it damage my kidney?
• How much does it cost?
• Do I have to keep taking this drug forever?

I have to admit that I used to take a deep breath internally when I explain why the drug will not damage the kidney or liver. I used to take it personally that a patient would think I would harm them by giving something that can fry the liver or kidney! I soon realized however that this was not personal. The patient truly wanted to know! More often, such information had come from family members or friends who had suffered diabetes complications.

Most patients do not object to my prescription after I answer their questions. Some have asked that their medicine be changed though at subsequent visits because of cost or side effects. Rarely, someone will object to a medication at the very start.

I had one such elderly patient at the clinic recently. He absolutely refused Metformin in the belief that it will destroy his kidneys. I was unable to convince him otherwise despite a lengthy explanation. On the other hand, insulin was perfectly acceptable to him, in contrast to my other patients.

I’ve seen decision aids for diabetes medications before. I must confess I don’t use them in my practice. Here’s one example from the Mayo Clinic.

I wish someone can make a local Filipino version of the Mayo Clinic costs decision aid below. As most of healthcare in the Philippines is out-of-pocket, this decision aid is particularly useful!

Below is a video demo of how to use these decision aids.

Do you use similar decision aids in your clinic? Are you a patient who wishes that his/her doctor will use these aids? Let me know in the comments.