The days of medical decisions being imposed on patients are long gone. Images of Sir Lancelot Spratt, in the film versions of Richard Gordon's Doctor books, yelling at his patients to do as they are told have faded into the archives. Even with doctors' modern communications training, however, the moment of medical decision-making remains a challenge. Many decisions fall into a grey area where the optimal choice for a patient may be unclear. Drug treatment, for example, may offer both appreciable benefits and appreciable risks.
Whether to use blood-thinning drugs for people with certain rhythm disturbances of the heart is a case in point. I recall a very robust 82-year-old being diagnosed with atrial fibrillation, a common heart-rhythm abnormality, during routine surgery to remove a cataract.
Inevitably, as the condition is associated with an increased risk of stroke, he was referred to a medical specialist with a view to starting anticoagulant treatment, using warfarin.
He came to see me somewhat upset and not a little confused. An earnest junior doctor at the hospital had painted a bleak future for my patient if he did not agree to start the new therapy.
But, he pointed out to me somewhat plaintively, "I'm in my 80s, I do not want to have to attend a warfarin clinic to have my blood checked every couple of weeks and I'm worried about side effects. Would aspirin not do the trick?"
It took two fairly lengthy consultations to iron out the issue. Eventually, having weighed up the risks of doing nothing, taking aspirin or agreeing to the blood-thinning treatment, he went with aspirin.
The episode was a good illustration of the need for doctors to discuss fully the risks and benefits of a treatment, as well as to assess thoroughly the patient's understanding. It is all too easy to seek a patient's agreement to a recommended treatment rather than quantifying the risks and benefits of alternative approaches.
In fact, a randomised US trial of a patient-decision aid for people faced with the same choice as my patient found that people opted for the anticoagulant treatment less often.
So how can doctors ensure the patient is the key medical decision-maker? Printed information is often inadequate: patients report that it offers too little information on the efficacy of treatment and does not deal adequately with self-management options.
A new generation of decision aids make choices explicit rather than implying a course of action that the physician would prefer. The best of them are interactive and allow individuals to obtain information tailored to their age and the severity of their disease.
Interactive computer technology allows the use of visual aids. Animated graphics make the information more "real", and other patients' experiences can be absorbed. Research has shown that a tailored interactive approach engages patients' attention and transmits information better than the traditional handout.
Two of the latest projects, which studied patients' decision aids in primary care, found that patients and physicians were happy to accept computer-based programmes, which also reduced the conflict associated with making medical decisions.
One study focused on 205 women, at a number of UK practices, making decisions about hormone replacement therapy (HRT). Some were offered access to an interactive multimedia programme that quantifies the risks and benefits of the therapy.
In particular, issues such as heart disease, osteoporosis, breast cancer and womb cancer were discussed in detail. The remaining women received normal clinical care, with the usual doctor-patient interview.
The research found that those who used the interactive decision-making aid felt more certain about their final decision and were more committed to the course of action they had opted for, whether or not that was to accept HRT.
Significantly, they did not become more anxious as a result of having to make their choices on the basis of such detailed information.
The same researchers carried out a similar study on men deciding on treatment for enlarged prostate glands.
They discussed their options, including surgery, drug treatment and "watchful waiting", in which patients decide not to intervene but to monitor the situation with their doctors, using an interactive programme.
Again, the study found that patients who viewed the programme played a more active part in the decision-making process.
Such aids could be introduced throughout the health service, at relatively low cost, by using the Internet. They could be accessed both in doctors' surgeries and in patients' homes.
It is hardly a revolution - yet any initiative that empowers patients and makes it clear there is often a choice about treatment must be welcomed.
You can e-mail Dr Muiris Houston, Medical Correspondent, at mhouston@irish-times.ie or leave a message on 01-6707711 ext 8511. He regrets he cannot reply to individual medical problems
