Sunday, July 13, 2008

Shared Decision Making via the Archives of Internal Medicine: Are the Physicians Responsible for Doing It or Making Sure It's Done?

In a previous post, the Disease Management Care Blog alerted readers to a study demonstrating that the open access dimensions of the ‘patient centered medical home’ (PCMH) was not easy to implement and may have little impact on patient perception of quality.

The DMCB wants to alert readers to the arrival of another study that addresses the assumption that doctors – because, well, they’re doctors – are intuitively inclined provide to another element of the PCMH. This one had to do with shared decision making, or helping ‘patients actively participate in decision-making [bolding mine].’

In the July 14 Archives of Internal Medicine [not online yet at the time of this posting] Young and colleagues1 looked at the ‘shared decision making’ behaviors among 152 primary care providers in three U.S. cities who were surreptitiously visited by one or two ‘standardized patients’ (i.e., actors) feigning the classic symptoms of depression. Shared decision making was defined by the authors of this study as a ‘collaborative effort between physician and patient, who share information, preferences and concerns as they negotiate a course of action.’ The authors used an internally contrived scale based on 12 shared decision making dimensions on a 0-4 scale (zero none, 4 a lot) to analyze recorded conversations between the physicians and ‘patients.’ 12 x 4 = 48 is the maximum score. The mean score in this study was just over 11, which isn’t too good.

The paper was accompanied by an editorial2 in which 8 ‘myths’ were explored:

1. 'Everyone knows what shared decision making is.'

2. 'There is only 1 approach to shared decision making.'

3. 'Physicians [as opposed to patients] alone drive shared decision making.'

4. 'Most physicians engage in shared decision making – at least, they would if they had the time.'

5. 'Physicians do not have the time for shared decision making.'

6. 'Most patients would rather the physician tell them what to do.'

7. 'Patients who do not want shared decision making want their physicians to decide for them.'

8. 'Shared decision making, informed decision making and participatory decision making are the same thing.'

Neither the original study authors nor the editorialist explored the implications of their findings for the PCMH, but the DMCB thinks they are significant. While it’s been recognized that 'physician and practice behavior change’ will be necessary to implement the medical home using, for example, ‘web-based instruments and patient simulation,’ these data from the Archives suggest that mainstream primary care providers have a long way to go before they’ll be able to offer shared decision making in day-to-day clinical practice.

While we await that yet to be discovered secret physician-behavior-change sauce, the DMCB would like to point out that there are other approaches that depend less on the physician and more on other strategies. They are not only very effective but ready to go. In fact, they're already being implemented.

The Disease Management Care Blog suggests there is a myth number 9: ‘It is up to the physicians to provide shared decision making in their day to day clinical practices.’ The DMCB suggests they should be responsible but can rely on other professionals and/or systems to implement it more effectively.

Here are the references:

1. Young HN, Bell RA, Epstein RM, Feldman MD, Kravitz RL: Physician’ shared decision-making behaviors in depression care. Arch Int Med 2008;168(13):1404-1408

2. Hansen J: Shared Decision Making. Have we missed the obvious? Arch Int Med 2008;168(13):1368-1369

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