Patients at the center: in our practice, and in our use of language.

In their editorial about patients sharing decision-making responsibilities with physicians, Guyatt and colleagues (1) review some of the evidence that patients favor involvement in their own care. They neglect a more complex body of evidence, however, that suggests that while patients like the idea of greater choice, they often find it to be less satisfying in practice (2). Just as the authors suggest that physicians incorrectly “assume that physiologic outcomes will lead to improvements in mortality and quality of life,” they themselves assume that more choice will lead to greater patient satisfaction. As suggested by Barry Schwartz, a psychologist at Swarthmore College, the opposite may be true (3). Schwartz has identified a number of problems that arise as choices proliferate (4, 5). First, reliable information is difficult to obtain. The advent of the Internet has increased access to information, as Guyatt and colleagues contend, but the information being accessed may be unreliable or untrustworthy. Obtaining additional opinions and performing research are potentially costly and time-consuming. Another problem is that as options multiply, patients’ standards for what is an acceptable outcome rise, with a loss of perspective of what may reasonably be achieved. Schwartz also notes that people may fear making the wrong choice and allow that fear to guide their choices. Or, post hoc, they may come to believe that an unacceptable result is their fault, and that their choice of therapy was mistaken. As the saying goes, good judgment is the result of experience, and experience is the result of bad judgment. In one example of a study that stands in contradistinction to those cited by Guyatt and colleagues, people were asked to describe the role they would select in choosing their treatment plan if they had cancer (6). 150 women, newly diagnosed with breast cancer, were compared with 200 women with benign breast disease. Most of the women with breast cancer preferred a passive role, leaving the decision-making responsibility to their physicians; the benign disease control group preferred a collaborative role with decisions made jointly between the patient and the physician. Schwartz has written that “Indeed, there may be a point when choice tyrannizes people more than it liberates them” (7). Like the patients in the study cited above, my own mother, an intelligent, strong-willed professional, was faced with the choice between lumpectomy and mastectomy for breast cancer. She sought opinions from 2 oncologists, an internist, a gynecologist, and her son, a nephrologist. I thoroughly reviewed with her the medical literature of the day. Finally, after many weeks, her unwavering decision was a nondecision: to let me make the choice, without her offering any real guidance. For the rest of her life, she was grateful to me for having “saved her breast”. David S. Goldfarb, MD New York Harbor VA Medical Center NYU School of Medicine New York, New York, USA References 1. Guyatt G, Montori V, Devereaux PJ, Schünemann H, Bhandari M. Patients at the center: in our practice, and in our use of language [Editorial]. ACP J Club. 2004 Jan-Feb;140:A-11-2. 2. Schneider CE. The Practice of Autonomy: Patients, Doctors, and Medical Decisions. Oxford: Oxford University Press; 1999. 3. Schwartz B. The Paradox of Choice: Why More is Less. New York: Ecco; 2004. 4. Schwartz B. Self determination. The tyranny of freedom. Am Psychol. 2000;55:79-88. 5. Schwartz B, Ward A, Monterosso J, et al. Maximizing versus satisficing: happiness is a matter of choice. J Pers Soc Psychol. 2002;83:1178-97. 6. Beaver K, Luker KA, Owens RG, et al. Treatment decision making in women newly diagnosed with breast cancer. Cancer Nurs. 1996;19:8-19. 7. Schwartz B. Nation of second guesses. New York Times. 2004 January 22. www.nytimes. com/2004/01/22/opinion/22SCHW.html.