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Tuesday Aug 05, 2014

Skin in the Game: Shared Decision-making May Boost Patient Buy-in to Care Plan

My patient had been on a statin, but he stopped taking it because it caused muscle aches. However, he also had hypertension, and many of his immediate family members -- including both parents -- had died at young ages from heart attack or stroke.  

He was usually a gregarious and care-free individual, but on this day, I could detect concern in his voice. His older sister had recently been diagnosed with congestive heart failure, and this had him thinking about his own health. His blood pressure, usually well controlled, had been higher lately. Although he typically did not like taking medication, he was open to discussing it now.

I explained to him the utility of a clinical decision aid I like to use while I plugged in his demographics and recent cholesterol numbers. I watched the smile return to his face as we changed parameters to show how improving his blood pressure control would reduce his 10-year risk for cardiovascular events and more of the 100 dots on the screen that represented his risk turned from yellow to green. The statin had made little difference so perhaps he wouldn't need it after all.  

He seemed his old self again as he laughed and walked down the hallway out of the clinic.  

As physicians, we make many decisions every day. Some of these decisions are simple, such as starting a hypertensive patient on blood pressure medication. Other decisions can be complex and life-altering, such as discussing how aggressively to treat a patient with newly diagnosed advanced cancer. In much of the practice of medicine, there are many options for treatment, and often, there are potential benefits and risks to each treatment so there is no clear winner.

Shared decision-making has gained traction in the past several years as a useful way to approach these kinds of situations with patients. The Center for Shared Decision Making at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., defines it as "the collaboration between patients and caregivers to come to an agreement about a health care decision."

Shared decision-making stands in stark contrast to the age-old paternalistic approach to medical care where the patient comes to the physician, who is seen as the expert, and the physician tells the patient what to do.

With shared decision-making, the idea is to involve the patient and caregivers in the decision-making process and arrive at a decision that makes sense for the patient given his or her values and circumstances. Intuitively, it makes sense that patients may be more inclined to adhere to a plan they feel they had a part in creating. However, I have found that the tricky part of shared decision-making is educating patients about their options and the associated potential benefits and risks in a way they can understand. 

This is where patient decision aids come in. There are many resources out there, but they're not always easy to locate. You can find several on the Mayo Clinic's website(shareddecisions.mayoclinic.org), as well as the Agency for Healthcare Research and Quality website(effectivehealthcare.ahrq.gov). If all else fails, ask Dr. Google. 

Section 3506 of the Patient Protection and Affordable Care Act requires HHS to establish a program to create patient decision aids, so these should become more readily available -- and be tailored to different patient populations -- in the future.

However, the old adage "All that glitters is not gold" still applies. Barriers to and questions about implementing these decision aids in practice remain. Most physicians have never received training (content.healthaffairs.org)to use them and may not feel comfortable integrating them into patient visits. And using such an aid takes up precious time during the visit. There may be cultural barriers to using these aids in practice, and it may require extra insight into a patient's learning style. Would he or she respond better to written information, numbers or pictures? Concern also exists about bias in clinical decision tools. Who developed the tool, and would the developer stand to benefit from one decision over another? Some even argue there are situations in which biasing the tool toward a certain outcome, or patient "nudging," could be appropriate.

Finally, although it sounds like a logical and patient-friendly approach, there is little research to determine what benefits or harms the practice of using a decision aid may yield. Does it actually improve patient adherence? Does it help contain rising health care costs? What impact does it have on patient satisfaction and health? These are all questions that need to be addressed moving forward. 

Some of my favorite opportunities to apply a shared decision-making approach include discussions regarding prostate-specific antigen (PSA) testing, osteoporosis treatment, and use of aspirin or statins for cardiovascular event prevention. Interestingly, I have found that many men who come to my office requesting a PSA assay decide not to be tested after reviewing the risks and benefits. I have also found my female patients to be more apt to take vitamin supplements and start weight-bearing exercise to improve their bone density rather than rely on medication.

Now, you would think that patients would be ecstatic about this after all those years we have apparently just been bossing them around. Au contraire! Some of my patients are frustrated by this approach. "Isn't this why I came to you? Won't you just make the decision for me?" Although most of my patients have embraced the concept, there are those who require a bit more hand-holding. To be fair, the same could be said of us as physicians. I personally view one of my most important roles as a community physician to be that of educator, and shared decision-making fits that role perfectly. 

Shared decision-making is also a two-way street, and there is much I can learn about my patients' values and beliefs as we decide together how to best manage their health. 

I urge you to visit the links above, check out the decision tools and then try to incorporate them into a patient visit or provide them as resources for your patient before a visit to stimulate discussion. I would also be interested to hear in the comments field if you have particular decision aids you like or have had interesting experiences using this approach with your patients. Have you had any negative experiences or pitfalls from which we all could learn?

Peter Rippey, M.D., is a board-certified family physician who maintains a private practice in rural Missouri. He enjoys a full-spectrum practice with a focus on community and collegiate athletic coverage.

Posted at 11:35AM Aug 05, 2014 by Peter Rippey, M.D.

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