We all want the same thing from our health care – to achieve the best possible health outcomes while avoiding harmful unnecessary care. But how do we get the right care in a health system that emphasizes doing more instead of doing better? The key is asking the right questions, says Gary Fradin, a long-time teacher and researcher of health literacy. We talked to Fradin about how to spark necessary conversations between doctors and patients, the ubiquity of misinformation, and more.
Lown Institute: Tell us about how you got involved in education around health literacy
Gary Fradin: A long time ago, I studied public administration at Harvard. Whenever we evaluated a program, we would ask the questions, “How well does an intervention work?” “Who benefits and who loses?”
It occurred to me that we don’t ask these basic questions in health care. Somewhere along the way, we stopped asking, “How well does it work?” and just asked, “How does it work?” We get too involved in the mechanisms. From a public administration background, this doesn’t make sense.
Why is “How does it work” not the right question?
We often get caught up in the mechanisms of health care interventions, so we ask how something works. But treatments all sound good if you just talk about the mechanisms. It happens very often — almost half the time — that a new intervention that is biologically plausible (for example, opening up arteries with stents prevents heart attacks) turns out not to be more effective than existing therapies.
What questions should we be asking in the doctor’s office?
In the presentation I give to insurers and patients, I include four key questions that patients should ask their doctor before every medical intervention:
- Out of 100 people like me (people with similar age, risk factors, etc), how many benefit and how many are harmed according to studies?
- Is it overused in the real world?
- Would most physicians make the same recommendation or might some suggest something different?
- How many patients like me do you treat annually?
Where did these questions come from?
The questions are designed to help patients learn more about an intervention before they agree to it, in the same way you would do research before making any big purchase. For example, before you buy a car, you would want to know: How well does the car work? What are my options for types of cars to buy? Which company makes that type of car best?
The first two questions help doctors and patients understand how well an intervention works, both in studies and in the real world. The third question starts a conversation about the options for treatment. And the last question helps patients find out the level of experience their doctor has with the option the patient decides is right for them.
What if a doctor doesn’t know the answer to a question?
“I don’t know” can be an acceptable answer, because sometimes the research does not exist yet. But asking the question should open up a conversation about the risks and benefits. What you don’t want to hear from a clinician is, “The treatment reduces your risk by 30%” or “Side effects are infrequent.” These answers don’t give you an idea of your absolute risk.
If you ask your doctor a question and they don’t want to answer it, that doesn’t mean the conversation is over. I would tell the doctor, “If you don’t know the answer that’s okay. But I’m uncomfortable proceeding without talking about this first.” This is why medical literacy is so important. The better you understand the issues, the more confident you will be in pursuing the conversation.
Someone who took one of my classes later told me that he had asked both his cardiologist and dermatologist, “Out of 100 people like me, how many benefit from this intervention?” The cardiologist said, “I don’t know, let’s find out” and they looked at some of the research together and talked about it. This helped the patient feel more comfortable asking questions of his cardiologist and helped them build a better working relationship.
When he asked the same question of the dermatologist, the doctor said, “If you don’t trust my judgement, you can find another doctor.” So he learned an immense amount about these health providers just from one question.
How important is medical literacy to facilitating shared decision making?
Medicine is both an art and a science. These four questions and the discussions they provoke help uncover the scientific part, the facts. The art comes from interpreting those facts, determining if an intervention works well enough for a specific patient and applying the doctor’s experience and wisdom to the patient’s needs. Medical literacy is necessary but insufficient alone to make wise decisions.