Health Care Decision-Making

Patients' perspectives of the ideal dentist

  • Investigator: Kevin I. Reid, D.M.D.
  • Funded by: Mayo Clinic Program in Professionalism and Ethics

Writers have recently expressed concern that the practice of dentistry has changed from a profession based on traditional ethics of health care to a for-profit business in which treatment recommendations are based on profit potential rather than the primacy of patient welfare.

In addition, the most recent Gallup poll that included a survey of dentistry reveals a declining trend in how the public views the ethical standards of dentists, showing that fewer than 60 percent of respondents would rate the honesty and ethical standards of dentists as "high" or "very high." Underlying these disconcerting issues are questions about the prevailing moral landscape of the profession of dentistry and therefore about normative ethical values and behavior of dentists.

Dr. Reid and his colleagues assert that patients know what characteristics they want to see in their dentists, physicians and others. In this study, Dr. Reid seeks to define the moral characteristics of the "ideal dentist" from the perspective of patients.

Ethical and policy challenges in implementing shared decision making in the wake of U.S. health care reform

  • Investigator: Jon C. Tilburt, M.D.
  • Funded by: Greenwall Foundation Faculty Scholars Program, Mayo Clinic Program in Professionalism and Ethics, and Mayo Clinic Center for the Science of Health Care Delivery

In its current form, U.S. health care costs too much, delivers too little and creates wide disparities in health outcomes. Physicians contribute to this problem as key drivers of health care resource utilization. They should also contribute to finding solutions.

The Patient Protection and Affordable Care Act, passed into law in 2010, introduced several bold provisions to encourage the use of shared decision making, a model of decision making grounded in respect for and fidelity to the interests of individual patients. Health care reform legislation attempted to reconcile the enduring ethical tension of modern medicine by harnessing physicians' duties to respect individual patients — embodied in the ideal of shared decision making — for the purposes of promoting the just distribution of health care resources in society.

Whether, how or to what extent cost-containment in health care should be an explicit objective of health care reform generally or shared decision making in particular is a thorny question about which physicians disagree. If physicians view shared decision making as a mere instrumental means by which health systems seek to improve reimbursement or as a government strategy to stem the rising tide of health care costs at the bedside, the intrinsic value of shared decision making could be compromised irreparably.

Dr. Tilburt and his colleagues want to know: Will U.S. physicians object to or support shared decision making as a means of achieving cost containment? This study will assess physician beliefs and values surrounding cost containment strategies and the practice of shared decision making in the clinic setting.

The investigators plan to:

  • Conduct focus groups with Mayo Clinic physicians
  • Build a conceptual model of factors influencing physician judgments about cost concerns in shared decision making using information from the focus groups
  • Devise, pilot and disseminate a national survey to 3,000 U.S. physicians to explore more systematically the beliefs, norms and judgments toward and predictors of receptivity to shared decision making generally but with particular attention to issues of cost

In doing this, Dr. Tilburt seeks to derive a framework of professional and ethical norms that shape physicians' judgments about of the role of cost containment in shared decision making. From this, Dr. Tilburt and his colleagues will critically examine the implications of those norms for a reformed U.S. health care system.

Assessing the patient experience in cancer care: An observational communication study

  • Investigator: Jon C. Tilburt, M.D.
  • Funded by: National Institutes of Health grant number R01 AT006515

Communication is an important component of comprehensive cancer care that impacts patient satisfaction, adherence and quality of life.

The wide array of issues addressed in cancer clinical interactions makes communicating about a broad range of topics — including quality of life, communication, symptom control, complementary and alternative therapies, costs, treatment burden, prognosis, anxiety, side effects, sexual function, palliative care options, and more — especially interesting and potentially challenging.

Some of these topics may not be routinely addressed in the clinical interaction or may require consultative support from other members of the comprehensive cancer care team. One frequently overlooked critical element in research on communication among cancer clinicians, their patients and patients' primary care clinicians is describing real-time consultations between patients and their clinicians.

These interactions provide rich material for assessing key psychosocial dynamics and identifying issues that patients find important in their care. In order to devise systems of care that optimize the patient experience, it is critical that clinicians and researchers understand, appreciate and systematically characterize the richness and complexity of the decision-making process in routine cancer consultations between cancer patients and their treating clinicians.

This study seeks to assess the patient experience in cancer care by observing patients and their physicians in their clinical interactions and following them for several months to see how their care went. By describing in depth the conversations and experiences of patients in these clinical interactions, this study will lay the foundation for practice-based interventions to optimize patients' interactions with their cancer care teams.