Shared-Decision Making — A Method to Creating Positive Outcomes

“No Decision About Me Without Me,” a directive for patient care from Prime Minister Clegg of the Netherlands.  The vision is for patients and clinicians to reach decisions about treatment together, with a shared understanding of the condition, the options available, and the risks and benefits of each of those.

While this is the ultimate goal of shared decision-making, how are our healthcare systems and care providers doing with listening to patients and including them in all decisions regarding their healthcare? An in-depth discussion with Tracy Walsh, an Experience Advisor at Planetree, lends great insight into this question.

“While we’re making progress with shared decision-making, we have a long way to go,” states Walsh.

Recent stats support Walsh’s assessment:

  • Physicians on average interrupt patients within the first 23 seconds of their opening comments. JAMA. 1999
  • Physicians do not ask patients if they have any questions in more than 50% of outpatient visits. Circulation. 2008.
  • Physicians typically spend < 1 minute of a typical visit discussing new prescriptions. Patient Education and Counseling, 2009.
  • Patients are afraid to ask their doctor questions for fear of appearing to challenge them. Health Affairs, 2012.

“Shared decision-making is a two-way street,” says Walsh. “It is a process which primarily focuses on chronic conditions or illnesses such as Asperger’s, cancer, diabetes, etc. It’s not as relevant to acute conditions such as strep throat where treatment protocol is relatively simple, and known.

Communication Pitfalls

Perhaps it comes from the limited time allotted for appointments or the assumption that most patients research their treatment options before their appointments. “The idea of shared decision-making is a change for hospitals. Right now patients agree to informed consent for treatment; that is one-way decision-making. The patient is informed of the risks and benefits, then signs a form to get the procedure or not. There are no choices,” Walsh said.

Walsh cautions, “The fault for lack of shared decision-making does not just lie with the care providers. Patients need to be educated and ask questions.”

Decision-Aids 

Preparing the patient prior to the appointment is key in shared decision-making.  Care providers can provide patients with decision-aids or a list of pros and cons for various treatments to help them weigh their options before meeting with their care provider.

The benefit? Knowing treatment options ahead of time enables patients to come to their appointments educated and well versed in the topic(s) needing to be discussed. It actually creates the opportunity for the care provider appointment to be more productive, generating engaged discussions between care providers and patients that result in mutual agreement about treatments.

Implementing A Process

There are many questions about providing patients with information:

  • How do we help healthcare organizations implement processes to provide patient information?
  • At what point does the patient receive the decision-aid (at home, in the waiting room, how and where)?
  • Who ensures the patient understands the aid?
  • What format is the aid? Online info, handout, or video?

Planetree is successfully working with healthcare organizations to find the best solutions for implementing decision-aids and creating processes that work based on patient populations. There is no single aid that works for all organizations. They are tailored to fit the uniqueness of each organization and specialty.

“While care providers have often provided information on treatments,” said Walsh, “they need to think about the training required to successfully educate patients as well as how and when to use which tools.”

The following graphic demonstrates the disconnect between care providers who think they are providing shared decision-making vs. the impressions of patients.

“If you talk with those in organizations that aren’t really implementing shared decision-making, they’ll often tell you they are using it and that they don’t have time to implement any additional tools,” comments Walsh. Perhaps this is true, but in reality giving the tools to patients in advance may result in better treatments. Yet, it’s difficult for organizations to change processes.

What the Future Holds

Effective, good medicine and research support the use of shared decision-making. “In the future, physicians are going to be trained in medical school on shared decision-making, decision-aids, and how to implement processes to better support patient-care provider communication,” states Walsh.

In the meantime, patients need to realize there are often other choices to be explored regarding their care. They need to be very engaged in their own care — researching options to help make tough decisions. While putting the burden on patients to be proactive can be overwhelming, and even emotional, there are online resources and apps available to help, including PatientsLikeMe, and those specific to healthcare systems such as MediPlanner.

Many healthcare facilities are also helping to make conversing and research easier by updating their spaces to help engage in patient communication, including adopting different view of the patient and care provider relationship by examining barriers to communication such as large computer screens; Considering others who are involved in patient care such as family members or loved ones and how to best include them in the process; and, creating spaces to support interaction, not just physical exams.

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