For over a generation now, efforts to make health care more patient-friendly have focused on getting patients and doctors to work together to make decisions about care and treatment. Numerous research papers, conferences and advocacy organizations have been devoted to this topic of “shared decision-making,” and even politicians have clambered aboard the train, devoting several provisions in the Affordable Care Act to “preference-sensitive care.”

But one thing has been missing in nearly all of these earnest efforts to encourage doctors to share the decision-making process. That is, ironically, the patient’s perspective.

Now a study published in the most recent issue of Health Affairs has begun to uncover some of that perspective, and the news is not good. In our enthusiasm for all things patient-centered, we seem to have, as the saying goes, taken the thought of including patient preferences for the deed.

The researchers conducted several focus groups with 48 patients from five primary care physicians in the San Francisco Bay area. First, they showed the patient participants a short video on several equally effective but very different treatment approaches for a heart ailment. Then, they asked them questions about what they did with their own doctors when faced with a choice among several treatment options that might be equally effective but could differ in lifestyle effects, cost or range of complications. Finally, the researchers asked the participants if they were comfortable asking doctors about different treatments, discussing their values and preferences or disagreeing with their doctors’ recommendations.

The participants responded that they felt limited, almost trapped into certain ways of speaking with their doctors. They said they wanted to collaborate in decisions about their care but felt they couldn’t because doctors often acted authoritarian, rather than authoritative. A large number worried about upsetting or angering their doctors and believed that they were best served by acting as “supplicants” toward the doctor “who knows best.” Many also believed that they could depend only on themselves for getting more information about treatments or diseases. Some even said they feared retribution by doctors who could ultimately affect their care and how they did.

The findings fly in the face of previous optimistic assumptions about shared decision-making that were based mostly on studies that examined physicians’ intent, but not patient perceptions. “Many physicians say they are already doing shared decision-making,” said Dominick L. Frosch, lead author of the new study and an associate investigator in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute in California. “But patients still aren’t perceiving the relationship as a partnership.”

Interestingly, most participants in this study were over 50, lived in affluent areas and had either attended or completed graduate school. “It’s hard to think that people from more disadvantaged backgrounds would find it any easier to question doctors,” Dr. Frosch said.

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As the country faces a projected shortage of 45,000 primary care physicians by the year 2020, osteopathic medical students are stepping up to fill that void.

CHICAGO, IL — Family medicine continues to be the largest matched specialty among osteopathic medical students, according to the National Matching Services, Inc., which recently announced the results of the 2012 osteopathic match.

Of the 2,373 individuals who participated in the American Osteopathic Association (AOA) Intern/Resident Registration Program, 75% of students and recent graduates successfully matched for a total of 1,767 placements. Last year, there were 1,640 successful matches.

Primary care specialties of family medicine saw a 16% increase and internal medicine saw a 21% increase from last year. Family medicine was the largest matched specialty with 433 positions filled. Last year family medicine also was the largest matched specialty with 373 positions filled.

"Each year an increasing number of osteopathic medical graduates are matched successfully into funded AOA residency positions. With the rate of annual increase noted and the success of the osteopathic post-match scramble, it is anticipated that virtually all available funded AOA positions will be filled in the next year or two," said Michael I. Opipari, DO, chair of the AOA Council on Postdoctoral Training. "In addition, we continue to see a significant increase in primary care specialty matches."

According to the AOA's 2011 Osteopathic Medical Profession Report, approximately half of osteopathic physicians (DOs) practice in the primary care areas, such as family medicine and internal medicine. Historically, DOs have had a special commitment to providing primary care, particularly in the nation's rural and underserved populations.

"As one of 20 DOs in my family, I have seen the legacy of the osteopathic medical profession being carried on by many generations of osteopathic medical students," said AOA President Martin S. Levine, DO. "Their contributions to all areas of medicine, including primary care, are essential in meeting our nation's health care needs. I wish the participants of this year's osteopathic match much success as they begin their new careers as practicing osteopathic physicians."

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