In the last few decades, shared decision making in healthcare has been a popular topic. According to the New England Journal of Medicine (NEJM), a consensus has emerged that decisions involving the choice among more than one reasonable treatment option should involve the patient (i.e., clinicians provide patients with information about all the options and help them to identify their preferences based on the patients’ values). While this makes sense, there are many ways in which decision making can be shared between clinicians and patients. Physicians describe processes that range from explaining the clinical situation and making a recommendation that the patient can accept or reject to outlining the treatment options and leaving the final decision to the patient.
Unfortunately, the role the patient is asked to play in the process is frequently not appropriately matched to the medical circumstances underlying the decision. The greater the uncertainty surrounding the options and the greater the clinician’s ambivalence about the “right” choice, the greater the likelihood that the patient will be asked to make the decision. Conversely, the greater the precision with which a decision’s outcomes can be predicted, the greater the likelihood that the physician will make a strong recommendation.
In reality, decisions that need to be made without clear information about the potential benefits and risks of treatment options are the most difficult ones to make and require the greatest input from a clinician. If a clinician is more likely to leave these decisions to patients, this results in missed opportunities to truly help patients and enhance patient engagement. These are the decisions for which patients, faced with complex information and uncertainty regarding benefits and risks, may gain the most from a recommendation. Furthermore, the clinician could use that recommendation to model for the patient how to think about the available information, including the areas of uncertainty.
Dr. Terri Fried, the author the NEJM article, believes that finding the sweet spot for shared decision making will require clinicians to work against their natural impulses to tell the patient what to do when they’re certain of what’s best and to leave the patient to decide when they’re not. “I’m not sure what the right answer is, so why don’t you decide” can be replaced with “This is a really hard decision because we aren’t sure what will happen if you choose option x; let me show you how I think about this, and you can tell me whether it fits with what’s important to you.” And, equally important, “I’m recommending option x because it provides better outcomes than option y” can become “Let me tell you about the pros and cons of options x and y so that you can decide which one matches your priorities.”
Massachusetts General Hospital (MGH) has actually tried to test the impact of shared decision making on patient engagement in the Shared Decision Making Program it implemented back in 2005. This program involves providing decision aids – booklets, videos and online resources – to patients to help them learn about their options and participate in decisions about their care. Dr. Leigh Simmons, medical director of the MGH Health Decision Sciences Center and a co-author of the Health Affairs report, shared, “After incorporating decision aids into their practice, physicians tell us that the conversations they have with patients are at a more advanced level, and they are able to focus on the things that matter most to their patients. Often they are surprised at how engaged patients are after using a decision aid.” In addition to the better quality of conversation being an indication of better patient engagement, the MGH study found a significant increase in the number of decision aid orders placed when patients were given the opportunity to select topics. The orders placed by patients also gave clinicians new insight into areas of patient interest.
According to Karen Sepucha, PhD, director of the MGH Health Decision Sciences Center and lead author of the report, the next step will be evaluating how successful the program has been in improving patient care. Sepucha says, “We survey patients to determine whether they are well informed about their treatment options, involved in conversations and receive treatments that match their goals. Ultimately, that will help us ensure that patients receive the care that is right for them.”
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