Shared decision making?

A surgeon may tell a patient that without surgery there is a 2% risk of stroke a year, whereas someone motivated toward medical therapy may rather state that there is a 98% likelihood that the patient will not have a stroke. Confusing? You bet!

As physicians and surgeons, we reach our conclusions after diligently evaluating the literature and our own clinical experience. Our judgment may take years to hone and may change as new developments occur, making it almost impossible to discuss options with a patient on a peer-to-peer level. It is therefore inappropriate to expect that we will be able to instruct the patient enough for them to make a truly educated decision. But in the spirit of “shared decision making,” we all should develop a simplified method of informing our patients so that they will be advised without becoming overly confused.

In my practice I make a point of discussing the controversy regarding asymptomatic carotid stenosis. I let them know that there are surgeons who operate for 60%, 70%, 80%,or not at all. I also try to instruct them on how difficult it is to be sure how tight the stenosis actually is. I discuss the difference between CEA and CAS and the pros and cons of each. I explain that many patients that we treat by CEA or CAS may never have needed the procedure, even if their carotid artery eventually occluded.

I tell them that over the years I believe I have helped prevent strokes but equally, some of the patients I treated may never have had a stroke even without CEA or CAS. And, of course, in trying to prevent strokes, I have caused them with my surgery. Lastly, I almost never tell patients what they should do, but leave the decision entirely up to them because they may be making the most important gamble of their lives, since the outcome of therapy is an odds game. By now you may be wondering how on earth any of my patients actually come to a decision. I am sure most patients would prefer that I make their choice easier by being more forceful in my recommendation. Unfortunately, their insecurity is the price they must pay for sharing in the decision-making process.