"With chronic diseases, the bulk of treatment has to be carried out by patients, at home, between office visits," says lead author Michele Heisler, M.D., MPA, a lecturer in the Department of Internal Medicine at U-M Medical School. "And because there are many different things that have to be done - and many tough behavioral changes - patients are more likely to be successful if they and their doctors agree on and target specific changes. Besides knowing their medicine, doctors have to be better coaches for their patients."
In the study, to be published in the November issue of the Journal of General Internal Medicine, researchers sent surveys to diabetes patients and their primary care physicians asking both groups to list their top three treatment goals and their top three treatment strategies for that specific patient. Of 127 patient-physician pairs, only 5 percent agreed on the three top treatment goals and 10 percent agreed on all three treatment strategies. Nearly one-fifth of patients and doctors did not overlap on any of their top three treatment goals.
But it's not all grim: Three out of five patients overlapped with their doctor on at least one treatment goal and more than half shared one treatment strategy. Fifty-five percent of patients included their doctor's No. 1 goal and strategy among their top three.
Patients who said they shared responsibility with their doctor for making treatment decisions were more likely to agree with their doctor's top strategies. Similarly, doctors who reported discussing more areas of diabetes self-management with their patients saw more agreement on treatment strategies.
"The main problem is that providers are not explicitly talking with patients about overall treatment goals and what strategies to prioritize. There is often more than one treatment goal that might make sense to target at any given time, which is why it's so important to set priorities," says Heisler, who is also an investigator at the Ann Arbor Veterans Affairs Center of Excellence.
In the study, patients who agreed with their doctors on more treatment goals reported being more confident about managing their diabetes and more successful at their self-management than patients with less agreement.
The findings can be extrapolated to include people with other chronic health conditions in which patients must monitor their health and often make and sustain difficult behavioral changes such as a strict diet or exercise regimen - including coronary artery disease, congestive heart disease, arthritis or chronic obstructive pulmonary disorder.
The key, Heisler says, is for patients to understand their condition and be aware of treatment options. From there, they should think through what health goals are most important to them and what strategies fit into their lifestyle. Above all, Heisler says, don't be afraid to raise questions or concerns with your doctor.
"Doctors are used to telling patients what they should do, often without giving very much information or being aware of the obstacles patients may face. We say, 'you should exercise more' or 'eat fewer fatty foods and sweets' without exploring patients' values and health priorities and without helping patients think of specific ways to achieve this. So when doctors just give short instructions, patients could take the initiative," Heisler says.
She also suggests patients tell their doctors some of the concrete steps they plan to take toward achieving health goals. Often, the doctor may have other helpful suggestions. On the flip side, patients also need to tell doctors when something is not working for them. For instance, if they would prefer to take fewer medications or if they struggle to fit in blood sugar tests during a work day, the doctor may be able to offer alternatives.
Often, doctors and patients end up working at cross purposes to each other when neither side understands the others' priorities. In this study, patients were more likely than their doctors to list avoiding insulin and getting off all medications as priorities, whereas physicians were the ones prioritizing lowering blood pressure or cholesterol levels. Although nearly three-quarters of the patients had hypertension, only 15 percent listed blood pressure control as one of their top three treatment goals.
The study authors suggest both patients and physicians need to define and explicitly discuss patient-specific health goals better. In particular, physicians must clarify why treatment recommendations such as lowering blood pressure are important.
"Patients often may disagree with a doctor's priority, but they usually don't share this lack of agreement with their doctor, and instead simply don't implement the recommendation," Heisler says. "Most research suggests that only about one-third of patients follow their doctor's treatment recommendations on a regular basis. To improve these numbers and clinical outcomes, it is critically important that doctors work with their patients to develop a workable treatment plan. The specific problems chosen to give priority to should be based both on their medical importance and the patient's motivation and readiness to address the problem."
Funding for this research came from the Department of Veterans Affairs Health Services Research & Development Service, the Robert Wood Johnson Clinical Scholars Program and the National Institutes of Health.
In addition to Heisler, the study's authors include Sandeep Vijan, M.D., M.S.; Robert M. Anderson, Ed.D.; Peter A. Ubel, M.D.; Steven J. Bernstein, M.D., MPH; and Timothy P. Hofer, M.D., M.S.
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