I would like to thank Dr. Vikas Saini and Shannon Brownlee at the Lown Institute in Boston for an exceptional Lown journal called the Right Care Weekly. Some of the best things I have read, aiming to get us doing the right things for the right reasons in healthcare, have come from Lown and the Right Care Alliance. The Alliance is a committed physician movement which I fervently hope will grow across the nation. The first important Right Care Alliance meeting on the road will take place on October 13, at the University of Colorado Medical Center in Denver.
The article which I reference in part below is one that was just published by the Institute of Medicine, in which Shannon was one of the coauthors. It talks about shared decision making (SDM).
What Is SDM?
For this paper, we consider SDM to be the process of communication, deliberation, and decision making during which:
- One or more clinicians share with the patient information about relevant testing or treatment options, including the severity and probability of potential harms and benefits and alternatives of these options given the specific nature of the patient’s situation;
- The patient explores and shares with the clinician(s) his or her preferences regarding these harms, benefits, and potential outcomes; and
- Through an interactive process of reflection and discussion, the clinician(s) and patient reach a mutual decision about the subsequent treatment or testing plan.
Since research has shown that extemporaneous conversations with clinicians often do not result in the effective exchange of reliable, complete, and balanced information, a structured tool can often enhance information exchange to support the process of SDM.
When Should SDM Be Pursued?
There are a few treatment decisions, such as whether to set a broken arm, for which there is such incontrovertible evidence of benefit and so few downsides, that clinicians and patients would be almost unanimous about what to do. While some have sought to limit the application of SDM to preference-sensitive decisions, this distinction is difficult to define and challenging to apply in practice.
We propose that the default position for every medical decision for which the options or results have health, financial, or quality-of-life implications should be that patients should be informed about their options and given a chance to have their informed choices honored when decisions are made. In particular, since patients must implement (and could in the process revise) many health care decisions—to fill prescriptions, attend visits, self-monitor blood sugars—SDM should be the aim for discrete decisions (such as whether to receive a certain screening test, or which treatment option to pursue for a given diagnosis) and also for ongoing, daily management and lifestyle choices for such chronic conditions as diabetes or high blood pressure.
What Is the Role of Decision Aids?
One way to promote SDM is to provide patients and clinicians with well-designed and structured decision aids, which are tools intended to provide detailed, balanced, evidence-based information about competing treatment options.
A 2014 Cochrane review of 115 randomized trials reported that using patient decision aids can lead to patients who are better informed about their options compared with patients who receive usual care. Decision aids enhance patients’ knowledge and understanding of the harms and benefits of various options, lead to more accurate perceptions of risk, greater comfort with decisions, decisions that align better with patient goals and preferences, and patients using decision aids are less likely to remain undecided (Stacey et al., 2011, 2014). There is also evidence that patients tend to make different choices when they have access to these tools versus usual care, and they are, on balance, more likely to choose less-invasive interventions.
In sum, while patient decision aids can help patients become better informed, and being informed may help patients engage with clinicians, ensuring that patients are informed does not necessarily ensure that patients are invited to “share” in the decision making process, or that their preferences are respected. The best decision aids, therefore, provide information and also encourage patients and clinicians to get on the “same page” with regard to options, evidence, preferences, values, and plans.”
Why Have I Written This Commentary?
For years, I searched for ways by which I can advocate for patients to become better equipped to make decisions about their health care. Too often, physicians rely on their professional gravitas to basically compel patient decisions. Remember Elisabeth Rosenthal’s excellent (and troubling) New York Times article where the surgeon told a patient compromised by excruciating pain “You need surgery, you won’t walk out of the hospital”?
I searched for and found a company that does an excellent job of encouraging patients to become more conversant and better involved in decision making, and then supports patients with information to do just that. That company does not interfere in the doctor patient relationship – they improve it by making conversations and decisions better.
I have spoken with employee benefit managers at major corporations about this. I don’t believe they intend to overlook and minimize the importance of steps designed to make right decisions and better decisions. They just have a great deal of information to process and a lot of people vying for attention, and so I don’t know if the decision making process has become a high priority in agendas about bending the employer’s cost curve. I hope it will.
Studies have shown repeatedly that when quality information is sufficient, decisions about surgery are often changed in favor of medical management that involves much less risk and expense. Back problems are a glaring example of how treatments facilitated by better investigations and questions can eliminate costly and ineffective spinal procedures. At one Fortune 100 company, such an approach reduced back pain-related costs by 50%, while vastly improving patients’ quality of life.
Information is power.