In 2017, Stanford professor Dr. John Ioannidis, Lown Institute Vice President Shannon Brownlee, and co-founders of the quality improvement group Delfini, Dr. Michael Stuart and Sheri Strite wrote about the ubiquity of poor-quality clinical research, what they call the “medical misinformation mess.”
Ioannidis et al. identified four key problems with clinical evidence:
- Too much medical research is of uncertain reliability, offers no benefit to patients, or is not useful to decision-makers. Bias is rampant due to industry funding, and many studies do not measure outcomes that patients actually care about.
- Health care professionals are unaware of the problems with medical research, and (justifiably) assume that because something is published in a journal, it must be good science.
- Many health care professionals, even those creating clinical guidelines, lack the skills to discern the reliability and usefulness of evidence.
- Patients and families don’t have access to accurate information and guidance when they need to make medical decisions, and clinicians rarely lead patients and families in conversations about the risks and benefits of treatment.
In a new article in the Journal of Evaluation in Clinical Practice, researchers Morteza Arab-Zozani at the Tabriz University of Medical Sciences, Ray N. Moynihan at the Institute for Evidence-based Care and University of Sydney, and Mohammad Zakaria Pezeshki at the Tabriz Medical School suggest that shared decision making can be the solution to reducing overuse that happens as a result of medical misinformation.
Bias and spin in clinical research leads both clinicians and patients to overestimate the benefits and underestimate the harms of treatments, which contributes significantly to overuse. Arab-Zozani et al. write that shared decision making can ameliorate our tendency to do more to patients, by addressing individual patients’ concerns, preferences, and treatment goals.
They define shared decision making as “an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences.”
When patients are empowered to ask specific questions about how a treatment will help them achieve their health and life goals, it encourages clinicians to examine the evidence around a treatment more critically. For example, the authors cite health literacy researcher Gary Fradin‘s four key questions that patients should ask their doctor before every medical intervention:
1) Out of 100 people like me (people with similar age, risk factors, etc), how many benefit and how many are harmed according to studies? 2) Is this intervention overused in the real world? 3) Would most physicians make the same recommendation or might some suggest something different? And, 4) How many patients like me do you treat annually?
A former smoker considering lung cancer screening may have heard that screening reduces their risk of death from lung cancer by 20%. However, by asking Fradin’s questions to their doctor, this patient would find out that out of 100 patients like him, 0.3 people would be saved from lung cancer over five years. At the same time, 2.5 people will have an abnormal scan result and will have to undergo further testing, which can be stressful and costly. The patient might also find out that the effectiveness of this intervention is still under discussion, and many physicians would choose not to recommend this screening.
By asking the right questions and having shared decision making conversations, patients and clinicians can help wade through the mess of medical misinformation and avoid harmful overuse. The authors also point out that movements like the Right Care Alliance are reinforcing the need for cultural change in health care, to ensure that patients receive all the care they need, and none that they do not.