Sunday, February 13, 2011

What Can A Hockey Game Tell Us About Shared Decision Making?

The Disease Management Care Blog attended a professional hockey game this weekend and it must say it was quite the spectacle. While the athleticism on the ice was quite remarkable, the real wonderment involved the hometown fans. Questionable referee calls prompted thousands of all ages to chant phrases that the DMCB has not recently read in any medical journals, while the willingness of grown men to display, in stereo fashion, obscene gestures was only last witnessed by the DMCB during an early morning ER shift.

Given their apparent fondness for calorie dense foods and various carbonated beverages, it was also clear to to the DMCB that wellness, prevention and chronic illness management was not at the top of most the hockey fans' agenda. Since there is a ready availability of high quality health care providers surrounding the hockey venue, the DMCB suspects most if not all of the gluttons on display were well aware of their downsides of their risky lifestyle.

So, is that their doctors' fault?

While the DMCB was at the American Medical Association's National Advocacy Conference, it was repeatedly reminded that the preferred physician answer is "hell no." While the DMCB's colleagues recognize the key to control of chronic illness is patient education, the sense of powerlessness over this issue was telling. Doctors talk, patients listen and, when the next visit rolls around, nothing has changed.

Enter "patient centeredness." This has been defined by the Institute of Medicine's Crossing the Quality Chasm report as any care that is “respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions." So, if a physician provides whole person care, comprehensive communication, coordination, support, empowerment and access on Friday afternoon and the patient washes three jumbo dogs and a plateful of nachos down with a pair of brewski's that Saturday night, is that a breakdown in a physician-owned care process?

Common sense says no, but our systems for quality improvement have yet to catch up with this reality. Ultimately, says the DMCB, patients should be able to fully participate in shared decision making and decide for themselves whether an ideal body weight, an A1c less than 7% or taking extra blood pressure pills is worth it. Assuming they've been apprised of all the risks, benefits and alternatives, that should be their decision to make. Given their behavior at the hockey game, patients certainly enjoy making full use of their right to make bad decisions.

Which leads the DMCB to three recommendations:

1. In addition to measuring "process," and "clinical," "economic," and "other" outcome measures, perhaps its time for the health care system to start learning how to measure "shared decision making" outcomes including counting the number of times patients at risk (the "denominator") participated in a state-of-the-art risk reducing, engagement seeking educational session (the "numerator"). The DMCB has little doubt that when this is done right, variation will diminish and the quality curve will shift toward the better. Physician buy-in will also increase.

2. Physicians should be free to assume personal responsibility for the task of seeking patient engagement during all the free time they have (not) during their face-to-face patient encounters. A more reasonable alternative may be to outsource this, either to the other team members in a patient centered medical home or to a companies (like this) that can scale this from one to thousands of patients.

3. Finally, hockey fans should recognize that persons unengaged in personal health improvement or risk reduction who also have no redeeming physical characteristics are not helped in their appearance by wearing a foam replica of an oversized hockey puck on their head.


Anonymous said...

patient centerdness may prove as successful as the public school system in which students have IEP's (individualized education plans) for all of their various and sundry special needs. Take notice how well the USA is ranked in the world in this venue. Unfortunately, the customer service model does not always translate into positive and quality customer lifespan.

Ben said...


Rachel said...

I think there is a lot to be learned about how and why people change. It's my observation that people don't change (blasphemy against DM, I know), but those who do change have very specific reasons and social support. I like what I've seen from Patient Activation Measure byJudith Hibbard and team. I'm not an expert, but it seems like PAM puts a spin on shared decision making to actually encourage change when possible.
*not a commercial, just an intrigued member of the industry