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Shared medical decision making: When one size does not fit all

According to many thought leaders, shared decision making is the pinnacle of patient-centered care.

Issue: August 2012

ByRichard Wexler, MD

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Shared decision making is a process that informs and involves patients in medical decision making. The shared decision making (SDM) model sits between an authoritarian model, where physicians make medical decisions for patients and a consumer model, where physicians provide information to patients, for them to make their own decisions.

The SDM model recognizes two experts – the physician is an expert in defining the clinically appropriate options, including the risks and benefits of each option, based on the latest medical evidence; the patient is an expert in their own values, preferences and concerns. The SDM process involves a two-way flow of information between the physician and the patient, each informed by the other, leading to a shared decision. Who first voices the decision is far less important than having the decision based on information from both experts.

According to many thought leaders, SDM is the pinnacle of patient-centered care. SDM encourages patients to participate in fateful decisions, that directly affect them. The importance of SDM is demonstrated by the fact that pioneer accountable care organizations must demonstrate that SDM occurs; Center for Medicare & Medicaid Innovation will evaluate it as one of 19 innovative care models; and notable organizations, including the National Quality Forum, American Medical Association and the American Academy of Orthopaedic Surgeons endorse it.

When and how to implement

Given the myriad of decisions clinicians make while providing patient care, significant patient involvement in all decisions is not feasible or desirable. SDM is often best suited for patients considering “preference-sensitive” care. There are many preference-sensitive care decisions in orthopedics. Take the example of choosing between joint replacement and medical management for osteoarthritis. While pain relief will likely be better with surgery than with medication, pain’s impact on lifestyle differs considerably from one patient to the next, as does one’s tolerance for risk and one’s ability to cope with the challenges of recovery and rehabilitation after surgery. Similar trade-offs are seen when patients consider the treatment options for herniated cervical or lumbar discs and many other elective surgeries.

 

Anthony M. DiGioia III,
Editor

 

Richard Wexler

While patient-physician conversations cannot be scripted, the six steps of SDM can be integrated into a conversation’s natural flow with a little practice. It is important to note that patient decision aides (pDAs) in print, DVD or web-based formats are often tools used to help facilitate steps two and three of the SDM process. These tools should present unbiased, accessible information, organized around specific decisions, and their available treatment options and their attendant benefits and risks. The best tools present high-quality evidence and numerical information using well-tested risk communication techniques. For example, risk reduction is presented in absolute rather than relative terms and 100-person charts are used to convey percentages. Ninety-six randomized controlled trials now conclusively demonstrate the value of pDAs. These trials show patients are more knowledgeable, more certain about their decisions and have more realistic expectations about treatment after using pDAs. Preliminary findings also suggest that if pDAs are used while obtaining informed consent, then there will be a decrease in malpractice awards due to failure to inform.

Models of implementation

There are a variety of models that have been used to successfully implement SDM and the use of pDAs. For greatest efficiency, pDAs are distributed to patients prior to scheduled visits and facilitate the SDM conversation with physicians during the visit. As many pDAs describe surgical interventions using high quality graphics in addition to providing average numerical information about benefits and risks, this information no longer has to be repeated during limited visit time. Rather, individualized risk and benefit information can be added if available, and other clinical considerations, unique to the individual patient, can be discussed. Preferably, this includes discussion about a patient’s personal goals and concerns. Many clinicians find having more personalized discussions rewarding.

A team-oriented approach to patient care, similar to the familiar team approach in operating rooms, continues to gain traction as a core approach to increase efficiency. Not surprisingly, clinical teams are an efficient way to deploy the use of pDAs and the process of SDM. Nurses or health educators, once familiar with the content of specific pDAs, answer questions that arise after viewing, help patients interpret information in the context of their own goals and concerns, and help patients prepare for physician visits maximizing consultation efficiency.

One novel model uses aspiring medical students as consultation planners who serve the above functions and also attend consultations capturing the answers to important questions for the patient and family to review after the physician visit. Another innovative implementation approach leverages shared appointments where a group of patients considering joint replacement surgery meet with a physician and nurse after viewing a pDA.

Although models of implementation may differ, the desired outcome of the SDM process is the same – informed and engaged patients who are able to make high-quality medical decisions that reflect their personal goals, concerns and circumstances.

Excellent resources are available for orthopedic surgeons who want to be more familiar with pDAs and SDM. For general information about SDM, including relevant health policy and implementation strategies, visit informedmedicaldecisions.org or the Dartmouth-Hitchcock Health System’s Center for Shared Decision Making at http://med.dartmouth-hitchcock.org/csdm_toolkits.html. An inventory of pDAs can be found at the Ottawa Hospital Research Institute’s website at http://decisionaid.ohri.ca/AZinvent.php. To learn more about the orthopedic-specific consultation planners model of SDM used by the University of California, San Francisco, please contact Kevin Bozic, MD, MBA, professor and vice chair of orthopaedic surgery at the University of California, San Francisco, Calif.; email: kevin.bozic@ucsf.edu.