Joint PCI decision-making may be a best practice, but it appears physicians aren’t encouraging it through their communication styles, according to a paper published online Aug. 25 in JAMA: Internal Medicine.

In this qualitative study, lead author Sarah L. Goff, MD, of the Baystate Medical Center at Tufts University School of Medicine in Springfield, Mass., and colleagues reviewed patient-provider discussions catalogued in the Verilogue Point-of-Practice Database. They took 40 patient encounters and developed a series of categories of dialogue factors that may have affected patient understanding.

They found that in reviewing the patient interactions, five main categories of communication stood out.

First, cardiologists approached patients with rationales for recommending PCIs and angiograms. Reasons ranged from presence of ischemia on stress tests, symptoms, assumed superiority or inferiority of therapies (oral medication vs. PCI) and questions about patient anatomy. Rationales for PCIs were found in all of the conversations physicians had with patients.

Goff et al recognized the second major communication category as being a discussion of the benefits of PCIs or angiograms, which also occurred in all cases with varying degrees of accuracy. In only 5 percent of encounters did physicians explicitly inform patients that a PCI would not improve risk of death but could improve angina symptoms. Thirteen percent of encounters gave PCIs overstated benefits.

In these conversations, cardiologists explicitly recommended PCI to prevent future heart attacks and other cardiovascular events. There were also a number of implied overstatements, leaving patients to conclude that PCI and/or angiogram would completely fix heart problems, implied cardiovascular disease was akin to a simple plumbing issue, that PCI was necessary instead of an elective intervention, or used messages framed in such a way that patients believed they would die without it. These subcategories encompassed 35 percent, 43 percent, 15 percent and 15 percent of conversations, respectively.

The third major category identified by Goff et al involved discussion of risks with patients. They noted that in many cases, cardiologists only discussed risks in a limited or oversimplified way. Cardiologists also sidestepped the issue, instead offering their level of expertise to imply that eliminated risks.

Communication style encompassed the fourth category. Goff et al wrote that this involved whether or not patients were engaged in decision-making about PCIs and angiograms.

In 75 percent of encounters, Goff et al found that the cardiologist’s communication style discouraged participation by using overly technical language, not listening to patients and not confirming patient’s level of understanding about PCI and/or angiogram. Only 35 percent of encounters involved communication styles that checked for understanding, provided patients with additional information about the procedure, connected with patients, or acknowledged and supported patients concerns, values and emotional distress.

The last category involved patient and family member contributions to the discussion. Goff et al noted that few patients asked detailed questions and while the presence of family members prompted more in-depth discussions, patient engagement in discussion was poor.

“We found evidence that cardiologists may contribute to patients’ misconceptions of benefit through explicit or implicit overstatement of benefits, understatement of risks, and communication styles that may hinder patient understanding and/or participation in decision-making,” Goff et al wrote. Further, they expressed concerns regarding how this misinformation could affect both outcomes and patient expectations.

While they could not specifically point to reasons for using these communication styles, Goff et al wrote that current reimbursement plans appear to favor a procedural approach over one that involves lifestyle changes and medication, suggesting that this may be one possible influence for recommendations.

Since all interventions, particularly surgery, come with risks, misperceptions leading to uninformed decision-making can have stiff consequences.

Goff et al wrote, “If physicians contribute to patients’ misperceptions of benefits, then interventions that use standard informed consent documents and patient decision aids may improve patients’ understanding and enable them to make decisions that are fully informed and consistent with their preferences, values, and goals.”