- The Washington Times - Sunday, June 12, 2005

LEBANON, N.H. - For 35 years after he accidentally shot himself in the leg, John Bevacqua managed just fine. But when a long-dormant bone infection reappeared and three surgeries did nothing to stop it, he agreed to an amputation.

The decision wasn’t easy. A unique program at Dartmouth-Hitchcock Medical Center, however, helped him realize that getting rid of his leg was the best way to get on with his life.

“I was almost on the verge of going through another operation,” Mr. Bevacqua said. “I was in doubt when I went in there, but when I was done, I knew I was going to do it.”

Mr. Bevacqua, 58, of Weare, put his hopes in the hospital’s Center for Shared Decision Making, a tiny office with a big mission: helping patients make better, wiser and potentially less-costly choices about their treatment by involving them more actively in their health care decisions.

The center provides free one-on-one counseling along with videos and digital video discs (DVDs) that explain the pros and cons of dozens of medical procedures. Though all hospitals routinely give patients information to help them make medical decisions, Dartmouth-Hitchcock is thought to have the nation’s only center dedicated to it.

Dr. James Weinstein, the center’s medical director, hopes it will move medicine beyond informed consent to informed choice.

“If you break your hip, you need to have your hip fixed because you can’t walk — you don’t have a choice. But when you have back pain or breast cancer or prostate disease or coronary artery disease, you have lots of choices,” he said. “Patients need to be empowered to make those choices.”

The center has won praise from the federal government, which is paying to replicate it at two other hospitals, in Concord and Laconia. One goal is determining how much money could be saved through shared decision-making.

Dr. Weinstein’s interest was sparked a decade ago when he participated in a research project at the University of Iowa. The orthopedic surgeon was surprised to see that some surgery rates fell by 30 percent when patients were given more information about their choices.

“I didn’t feel like [patients] were getting the information they needed to make their decisions,” he said. “They were talking to me, but maybe that wasn’t good enough, because I was a surgeon and surgeons do what surgeons do. Maybe they weren’t getting a fair shake.”

In another research project, he studied how spine surgery rates varied from region to region and estimated that $1.8 billion could be saved annually if the lower rates in some areas were the norm nationwide.

At the center, patients use computer touch screens to complete extensive questionnaires designed to help them identify and work through decisions. A bookshelf is crammed with videos and DVDs featuring medical professionals along with “real life” patients discussing their experiences. Not everyone leaves with his mind made up; many exit with detailed lists of new questions for their doctors.

“People who are struggling with a decision start to think in a very circular way, so their thoughts are chasing each other. You can almost see it physically when they walk through the door,” said Kate Clay, the center’s program director. “What I bring to the table is my expertise as a nurse and the ability to pick out what it is that seems to be really troubling them or what it is they need to move forward.”

Mr. Bevacqua credits Miss Clay’s patience and encouragement with helping him decide to go ahead with his amputation. After hearing that he would be capable of activities such as driving and swimming, he decided to forgo further surgery that would keep him on crutches for months and might not stop the infection anyway.

“I wish I did have my leg, but I’m not getting any younger,” he said. “It’s inconvenient, but I can go on with my life like anyone else.”

Miss Clay said as many as a dozen people per day stop by to borrow videos, and one or two per month get more extensive counseling. Since last year, all women diagnosed with early breast cancer have visited the center as part of a research project, and Miss Clay is working with other hospital departments to encourage making referrals to the center standard procedure.


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