What doctors say and what patients hear are often quite different, especially when patients are facing surgery or invasive medical procedures. That, in turn raises important questions about whether patients are truly "informed" when they give informed consent.
A group of cardiologists at Baystate Medical Center in Massachusetts explored that communications gap by studying how patients with chronic chest pain (angina), which often limits physical activity, perceived the potential benefits of elective angioplasty to open arteries narrowed by cholesterol-filled plaque.
In a study published in Monday's issue of the Annals of Internal Medicine, they surveyed 153 patients about to have heart specialists examine the insides of their arteries and if needed, perform angioplasty. They also surveyed 10 interventional cardiologists and 17 referring cardiologists.
The research team, led by Dr. Michael B. Rothberg, found that most chronic angina patients overestimated the benefits of angioplasty, even when they had read material provided by their doctors. The survey found 88 percent of the patients believed it would reduce their chances of suffering a heart attack and 75 percent thought that without it, they'd probably have a heart attack within five years. Patients expressed these perceptions even when most of their doctors knew the limitations of angioplasty.
Here is where some confusion may arise: Angioplasty indeed reduces the risk of heart attack and death in patients with acute coronary syndromes, in which plaque suddenly breaks off, blocks an artery and begins starving the heart muscle of oxygen. Acute cases account for the vast majority of the more than 1.2 million angioplasties performed each year.
But for chronic angina patients, angioplasty's benefits are more modest. It relieves chest pain and improves their quality of life for several years.
The study has two major implications. One is that patients may be inadequately informed about many kinds of procedures, and the other is that angioplasty may be described and "sold" by cardiologists.
"While the study was done in just one center, it rings true and the message ought to be heeded," said Dr. Mark Hlatky, a professor of health research and policy at Stanford University in Palo Alto, Calif.
Doctors long have debated how to best convey the benefits and limitations of treatments like angioplasty, but as busy doctors see more patients, that cuts into face-to-face time for detailed discussions about precisely what's at stake.
"We need to figure out better ways to inform our patients," said study co-author and interventional cardiologist Dr. Marc J. Schweiger. "What this study tells me is that we have to look further to figure out what works better and what doesn't."
Baystate is already doing that. It's among a dozen medical centers participating in an NIH-funded study of computer-based consent forms that give patients individualized risk profiles before angioplasty. Some of the 1,400 angioplasty patients Baystate hopes to enroll will face angioplasty for an acute heart attack; others for chronic stable angina, said Dr. Aaron Kugelmass, Baystate's chief of cardiology. "To the extent we can tailor a patient's likely benefit and tailor a patient's specific risk, I think that will go a long way toward creating an open dialogue and better dialogue between patents, their family members and physicians."