21 October 2016
Doctors should explain clearly to patients the medical evidence behind the options for treatment and allow them to take part in choosing them. Photo: Xinhua
Doctors should explain clearly to patients the medical evidence behind the options for treatment and allow them to take part in choosing them. Photo: Xinhua

Share decision making with doctor based on clinical evidence

Lai-shan, a slightly plump, moderately active woman with a stable body weight, visited the doctor for a follow up on her stable chronic diseases of hypertension and diabetes.

Reading her blood test results, her doctor coldly said he was going to prescribe her more pills, as her indexes of blood sugar and cholesterol were unsatisfactory.

Lai-shan was taken aback and asked her doctor to describe her condition in greater detail.

Her doctor glanced at her and spelled out her figures.

“Your glycated hemoglobin [HbA1c] is 7.3 percent, which is slightly higher than the optimal level [7 percent] of a diabetic person, while your ‘bad cholesterol’ [LDL cholesterol] is 3.2 mmol/L, which is also higher than the optimal level [2.6 mmol/L].”

Lai-shan begged her doctor to tell her whether it was possible not to take new pills if she is stricter about her diet and promises to do more exercise.

The doctor replied: “Research data shows that if blood sugar and cholesterol levels are not under good control, patients have higher risks for stroke, heart disease, kidney disease, amputation and blindness.

“In short, you would die early!”

The line “You would die early!” echoed in her head.

Is Lai-shan’s doctor telling the truth?

The research results her doctor cited came from evidence-based medicine.

Clinical research has found that for every 1 percent drop in HbA1c in a diabetic patient, his or her risk of stroke will be lowered by 12 percent, of myocardial infarction by 14 percent, of amputation by 43 percent and of death by 21 percent.

In other words, what this means is that poor control of a diabetic condition will increase one’s risk of death.

Yet, while translating these numbers into the conclusion “You would die early!” is not wrong, neither is it stating a fact.

Don’t forget the percentage lowering of risk we often hear about is a relative risk reduction. It is about relative risk, not absolute risk.

The actual benefits of a 1 percent drop in HbA1c are obviously very different between a diabetic patient with a stable condition and a diabetic patient with related complications.

The drop in death risk in the first patient would be insignificant, as the risk itself is basically not high, while it would be much more meaningful for the second patient.

Incidentally, would you like to discuss your well-being with someone like Lai-shan’s doctor?

From my perspective, doctors being paternalistic and deciding what information the patient needs to know is rather outmoded.

Patients should be well informed about their options after receiving a detailed explanation from their doctor.

It is also our responsibility as doctors to respect patients’ thoughts and values and assist in the promotion of their health in the way they desire.

Clinical practice should incorporate more shared decision making.

This article appeared in the Hong Kong Economic Journal on June 2.

Translation by Darlie Yiu

[Chinese version 中文版]

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Chairman of the Public Education Committee of the Hong Kong College of Family Physicians

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