Monday, May 7, 2012

How About Some Shared Decision Making on the Merits of Shared Decision Making?

"Shared decision making" (SDM) is a good thing, right? Defined as "model of patient-centered care that enables and encourages people to play a role in the management of their own health" it's achieved a level of admiration only exceeded by the Cat Daddy dance and owning Facebook stock.  Yet, while there's considerable research to support the immediate use of SDM in doctor's offices, it seems there's a problem.

No one asked patients what they think.

Well, this just published Health Affairs study summarizes the opinions about SDM that were gleaned from six focus groups involving 48 health care consumers (out of 458 patients contacted) who resided close to San Francisco.  Participants first watched a video that showcased how shared decision making worked and how it could be used to empower consumers to choose among several recommended treatment options. Then they were asked about their opinions.
The DMCB thought the results were disappointing.

Patients feel vulnerable.  They reported that:

1. they feel pressured to "conform" to a "role" that was subservient not only to the expertise of the physician, but his or her good will. Patients didn't want to be viewed as being "uncooperative."

2. it can be futile to overcome the authoritarian demeanor of their physicians. Patients feel powerless.

3.  there isn't enough time to reconcile the information they've collected on their own with the information at their physicians' fingertips.

4. They need to have at least one other family member or friend at the encounter. Patients are unable to absorb all the information they need to make an truly informed decision.

Up until now, the DMCB has assumed that the relatively low uptake of SDM in mainstream clinical care was a function of provider skepticism if not outright hostility. It seems another problem may be lingering patient doubts too.

Based on their results and a review of the peer reviewed literature, the authors offer some suggestions on how to foster the use of SDM including 1) increasing physician reimbursement, 2) developing efficient decision support tools, 3) increasing patient-physician face-to face time, 4) helping physicians become aware of the need for more open communication and 5) creating "signals" by the "system" that patient "engagement" is important.

The DMCB agrees, but points out that the road to SDM is not necessarily lined with physicians. They're busy and there's little room in the course of a clinic day for more disruptions of their work flow.  That's why it makes sense to think about SDM through the prism of population health management.  Here's why.

More on the topic in a future post.

Image from the SAMHSA website.

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