Shared Decision Making – Not Ready For Prime Time – Nor Evidently Is Patient-Centered Care

When it comes to delivering truly patient-centered care…how are providers supposed to know when they have “arrived”?   According to Michael Berry, MD, President of the Informed Medical Decisions Foundation, providers will know they have achieved the “pinnacle of patient-centered care” when they routinely engage their patients in shared decision-making (SDM).

In theory, shared decision-making (aka collaborative decision-making) is what is supposed to happen between patients and their doctors when faced with a difficult choice.  Clinicians engaging in shared decision-making would provide patients with information pertaining to the need for the treatment, the available options, as well as the benefits and risks.  But patient-centered clinicians would also do something else. They would attempt to work with patients to arrive at a decision they could both live with.  A kind of “shared mind” that takes into consideration their clinical perspective as well as the patient’s perspective – their preferences, needs, and values (which ideally have been captured over the course of the patient-provider relationship).

The Problem Is That Most Physicians Don’t Really Engage Patients In Either Shared Decision Making  

 A 2003 study surveyed U.S. physicians (N=1,217) preferences and actual practices regarding shared decision-making.  Table 1 presents a summary of findings from this study.

Table 1

Decision Making Style	What Physicians Preferred	What Physicians Actually Do
Shared decision-making	58%	37%
Physician-dominant decision-making	28%	43%
No patient involvement	9%	13%
Patient dominant decision-making	5%	7%

While most physicians in the study may philosophically believe in and prefer shared decision-making…as this data indicates that is not what most physicians in the study reported actually doing.  In fact, 56% of physicians reported that they actually engaged in decision-making that was physician-dominated (with some patient involvement) or totally physician-dominated decision-making behavior (absent any patient involvement).

The Barriers To Shared Decision Making?

The barriers to SDM include the usual suspects:

•  Lack of time during the visit
• Not having access to the right decision support aids tools and training their use
• Physician attitudes about patient’s willingness to engage in shared decision-making
• Provider reliance upon a physician-directed (versus patient-centered) style of communicating with patients

The Take Away – Why Shared Decision Making Matters

•  SDM is the right thing to do – the benefits associated with SDM include better outcomes, lower utilization and cost, lower malpractice risk and enhanced patient trust and satisfaction

•  SDM is a great way to be engaging to patients – it is a way to get patients involved in their care in a meaningful way they can relate to.

• To be eligible to participate in Medicare’s Shared Savings Program, Accountable Care Organizations must implement processes to promote patient engagement, including shared decision-making.

As readers of Mind the Gap know, I am a proponent of the adoption of patient-centered communication by providers, beginning with primary care.   Shared decision-making has rightly been identified as a leading indicator when it comes to assessing the “patient-centeredness’ of a physician practice.   So before you go around telling everyone how patient-centered your provider teams are first do a reality check.  Because if you aren’t regularly engaging your patients in shared decision making you are not there yet.

That’s my opinion…what’s your?

Sources:

Heisler, M. et al. Physicians’ participatory decision-making and quality of diabetes care processes and outcomes: results from the triad study. Chronic Illness. 2009 Sep;5(3):165-76

Street, R. et al  The importance of communication in collaborative decision making: facilitating shared mind and the management of uncertainty. Journal of Evaluation in Clinical Practice 17 (2011) 579–584.

Frosch, D., et al. An Effort To Spread Decision Aids In Five California Primary Care Practices Yielded Low Distribution, Highlighting Hurdles. Health Affairs. 32, no.2 (2013):311-320.

How To Speak So Your Doctor Will Listen

This guest  post was written by Vicki Whiting, Ph.D., MBA is a Professor of Management at Westminster College, and an Award-Winning Author of the health care advocacy book, “In Pain We Trust.”

Doctors interrupt patients 18 seconds into an office visit, on average. Given this fact, patients who seek to maximize their healthcare must learn how to speak so that doctors will listen. There are three communication skills that, when applied to a doctor’s visit, can increase odds that your physician will hear, and help solve the problem.

1st – Prepare what you will say. 

2nd – Know what you would like to achieve.

3rd – Formulate collaborative questions.

1) Prepare:The first step in effective communication is to prepare your message. Successful preparation for a doctor visit requires identification your primary health concern, symptoms relevant to this concern, and the length / frequency / intensity of each symptom. Stick to the facts, keep focused on what you believe to be relevant data, and keep your explanation short.

A friend called this morning. Her daughter has suffered from abdominal pain for four months and has begun to vomit after each meal. As my friend prepared for an appointment with a new specialist, she called to ask my advice.I got an earful of physical details, ailments, concerns about her daughter’s future, and conjectures about an injury five months ago that might be related to her daughter’s problems.

After two minutes I stopped my friend. I reminded her that her doctor would likely stop listening after 18 seconds. What did she want her doctor to know that could be heard in 18 seconds? After a bit of coaching she focused on the increase in her daughter’s focal pain, the fact that a diagnosis of SMA (Superior Mesenteric Artery Syndrome) was made, but was not being treated, and that her daughter has thrown up after each meal since a feeding tube was removed after a recent hospital stay.

Once the Mom’s message was stripped of dramatic details, non-related facts, and instead focused on relevant, actual elements of her daughter’s symptoms and medical history, chances that the doctor would listen to issues key to her daughter’s health greatly increased.

2) Communicate with purpose: Complex health concerns are solved in increments. If you have an earache, diagnosis and treatment is straightforward. However,appointments related to complex and chronic health issuesmake the desired outcome ambiguous for both the patient and the physician. If you don’t know what you want to achieve from the doctor visit, it’s unlikely that you will be content with outcome of the visit.

Since SMA is not cured in one doctor visit, my friend needed to think about a realistic outcome for the doctor’s appointment. “I want to understand the standard protocol for fixing SMA, and what plan the doctor recommends to fix my daughter’s SMA.” With this focus, my friend can leverage the doctor’s expertise, and start down a path of wellness for her daughter.

3) Prepare questions. To maximize the 14 – 16 minutes a primary doctor spends during an appointment (less for specialists) prepare questions you would like to have answered. If questions occur to you during the appointment, add these to your list. Some doctors are frustrated that patients spend time researching symptoms, medicines, and treatments on-line prior to an appointment. Given the amount of unreliable data available on-line, this is understandable. The key to being a good patient questioner is to base your questions on valid, reliable data, and your own symptoms and responses to treatment. The National Institute of Health is a great place to understand your medical condition, and what questions you might ask.

It is also critical that you have listened to your doctor throughout the appointment. Use questions to fill in gaps that might not have been addressed during the exam. Let’s go back to my friend and her daughter. The Mom wanted to ask the doctor if surgery would fix her daughter. I cautioned against asking this question. While mentioned as a cure for SMA on some websites, this is not a standard approach to resolving SMA. Also, based on information shared during the appointment, this question might not be relevant.

Finally, avoid questions that begin with “Why?” Why questions invite defensiveness. Why is my daughter sick? Why didn’t they fix her at the hospital? Instead, ask collaborative questions. What do you recommend?What would you do if you were in my shoes? Do I understand that you want me to…? These questions draw on the doctor’s expertise, invite thoughtful response, and focus on problem resolution.

To maximize time spent with your doctor, focus on the portion of the physician – patient interaction that you have control over – how you speak to your physician.  If you prepare for the appointment, focus on what you would like to achieve from the office visit, and formulate meaningful, collaborative questions, you’ll help yourself and your doctor create positive health care outcomes.

Dr. Whiting consults for health care organizations and providers across the United States on leadership, communication, and management issues. Contact: @docwhiting vickiwhiting.com, or vwhiting@westminstercollege.edu

The Traditional Patient “Sick Role” Is A Major Barrier To High Quality Health Care

Each of us wears many different “hats” throughout the course of the day.  We are an employee, a wife, a father, a club member, a consumer and so on.   It comes as no surprise that our thinking, what we say, and how we say it at any particular time coincides with the hat we are wearing at that moment.   The thing about these “hats” or roles is that they come with their own set of social conventions, particularly when it comes to how we communicate.   When I was a kid for example “children were to be seen and not heard” when out in public.

So it is when we put on our patient hat – something we all do from time to time, particularly as we get older.

Unfortunately few of the roles we play come with a book of instructions.  Rather we learn them from experience or by watching others.

Think back to your first visits to the doctor – when your Mom took you to the pediatrician.  If your experiences were like mine you learned very early on that the doctor did all the talking (aka physician-directed style of communication). That’s because the doctor’s role was that of “respected expert” and my Mom’s role (and by default mine) was to play the sick role.   Much was required or expected of the person playing “sick role”…you just were there to listen and then do as told.  My Mom never was one to be passive or  quiet in most social situations but when it came to being a patient (surrogate) or a real patient in later years…she would have won an Academy Award for playing the sick role to perfection.

Believe it or not, when I have to put my patient hat on…I am no different.  In another post, I described waiting 2 hours to see a new Retinal Surgeon who was said to be very good.   The longer I waited the fewer the questions I decided to ask him…he appear too busy to spend time with little ole me answering my questions.   I couldn’t believe how easily I slipped into the sick role!  I suspect that, contrary to all the talk in the literature about how empowered everyone is…we patients basically all behave the same way when the exam room door closes.

This point was driven home for me in a recent Health Affairs article that talked about “Patient’s Fear of Being Labeled Difficult.”  The basis for the article was a series of patient focus groups conducted in the San Francisco Bay Area – the heart of Silicon Valley and all things involving digital health.   One finding stuck me – that most participants in the study talked about how they actively tried to avoid challenging their physicians during office visits.   

Deference to authority instead of genuine partnership appeared to be the participants’ mode of working.

Mind you the participants in the research were “wealthy, highly educated people from an affluent suburb in California, generally thought to be in a position of considerable social privilege and therefore more likely than others to be able to assert themselves.”  These patients were recruited from Palo Alto Medical Foundation physician practices … one of the most wired health populations in the US!

But.. But.. Everyone Is Supposed To Be Empowered and Activated?  

Baloney.  The patients in the study were socialized into the same sick role as the rest of us.  Deference and passivity, at least while in the exam room with the physician, are dead giveaway signs of sick role behavior.   Too be sure these people did go online after they left the doctor’s office to do what they should have done with their doctor – ask important questions.   Did you know that during the average primary care office visit patients ask very few “important” questions?

The Finding Should Be Concerning To All Of Us

Talking (and listening) is how physicians diagnose and treat patients.  If patients are deferential (due to fear , concern about taking up too much time, etc.) to  their physician to the point that they don’t share valuable information, don’t ask challenging questions and don’t engage in collaborative decision-making  then something is very wrong.   The net result is sub-optimal outcomes, medical errors, preventable ER visits and hospital readmits and poor patient experiences.

The Take Away

The first step is for providers to recognize the scope of the problem and the need to fix it.  The second step is for providers to examine their own attitudes and skills with respect to helping patients break out of the sick role into a more collaborative role.  Third, providers and their hospital partners need to acquire the tools, training, and resources needed to help patients as well as themselves design and adapt to their new hats, roles, and social conventions.

That’s What I Think…What’s Your Opinion?

Source:

Frosch, D. et al.   Authoritarian Physicians And Patients’ Fear Of Being Labeled ‘Difficult’ Among Key Obstacles To Shared Decision Making. Health Affairs.  No. 5 (2012): 1030–1038

Patient-Centered Communications – Does “Lack of Time” Justify Physician Reluctance To Adopt It?

I talk with lot of physicians about the need to improve the quality of communications between physicians and patients.   Regular followers of my work will know that I am an advocate for the adoption of patient-centered communication skills by the physician and provider community.

Physicians with whom I talk seldom disagree as to the need for better physician-patient communications.   They know that physician communication skills top the list of patient complaints about their physicians, i.e., my doctor doesn’t listen,” “my doctor ignores me,” and so on.   Rather, they simply dismiss the subject out of hand as being impractical due to a “lack of time” on the part of most physicians.

I can understand their perspective.   Primary care physicians in particular are faced with sicker, more demanding patients, increased payer and regulatory requirements, and are constantly pressured to see more patients.

Yet physician waiting rooms and exam rooms are full of engaged patients (otherwise they wouldn’t be there) who have nothing to do but read outdated magazine.

What would happen if physicians actually put patients to work during wait time?

Here’s what I mean…

What if physicians integrated patient “wait time” into the office visit by:

• Talking to patients (via printed handouts, electronic media, patient portals, etc.) about their evolving new role (and that of the physician and other providers) under health reform.  Contrary to the popular press which touts the empowered patient, most of us still assume the traditional “sick role” during the office visit.  The sick role is characterized by patient passivity, limited information sharing, and minimal question-asking.

• Teaching people while waiting how (using the same media as above) to become “better patients.”   I recall an article where physicians were asked 5 things they wished their patients knew.  At the top of the physicians’ “wish list” was a desire for patient’s to be better prepared and more focused during the visit.  The point being that more prepared patients would help the physician get to the correct diagnosis and treatment plan faster

All of us, beginning in childhood, are socialized into playing the sick role when interacting with physicians.   Just as chronic disease patients needing to develop self care skills and confidence in their self care skills…patients need to be taught skills for (and develop confidence in) how to more effectively talk to and collaborate with their physicians.

•  Laying out a game plan (over a series of visits) for teaching new and established patients when and how to effectively contribute to the medical interview (exam).   Given an average wait time of 22 minutes per primary care visit, it is not reasonable to assume that patients can be taught the above in the course of 1 or 2 visits.  But patients with chronic conditions often visit their PCP 6-8 times a year.  This would afford plenty of time (2-3 hours a year) for physicians to teach (and practice) individual skills to patients (i.e., agenda setting and prioritization, question asking skills, self-care management skills, new medication considerations, etc.).   By reinforcing lessons learned by patients over the course of several visits, it is reasonable to expect that both patient and physician will become more proficient in the use of their time together.

How Exactly Will Better Physician-Patient Communication Lead To More Productive Visits?

Research has consistently shown that patient-centered communications (versus traditional physician-directed communications) can result in more productive office visits as measured by 1)  the amount/quality of information shared by patients, 2) the number of questions asked by patients, and 3)  and the level of patient retention of information shared by physicians.

These same studies show that the adoption of patient-centered communications adds little if any more time to the length of office visits.  Once patients and physicians become proficient in the use of patient-centered communications methods,  physicians may well be able to do more during the visit but in less time.  Here are some of the techniques  characteristic of patient-centered  communications associated with increased visit productivity:

•  Concise visit agenda setting and prioritization wherein both physician and patient  agreed to what can be discussed within the time allowed.  This  also eliminates  the “oh by the way” introduction of last-minute patient agenda items that can occur at the end of the visit.

•  More concise  sharing of relevant information by the patient.

• Greater physician-patient agreement as to the diagnosis and treatment.

• More collaborative decision-making

•  More information retention by patients (how to take new Rx, etc.)

• Greater patient adherence

That’s my opinion…what’s yours?

Related Post:

Do Medical Home Physician Really Communicate Any Better Than Non-PCMH Physicians?

Six Seconds To More Effective Physician-Patient Communications

Sources:

Politi, M. C., & Street, R. L. (2011). The importance of communication in collaborative decision making: facilitating shared mind and the management of uncertainty. Journal of Evaluation in Clinical Practice, 17(4), 579-84.

Bertakis, K. D., & Azari, R. (2011). Patient-centered care is associated with decreased health care utilization. Journal of the American Board of Family Medicine : JABFM, 24(3), 229-39. doi:10.3122/jabfm.2011.03.100170

Marvel, K, Epstein, R, Flowers, K, Beckman H.  Soliciting the Patient’s Agenda, Have We Improved?  JAMA. 1999;281:283-287.

Will Information Technology Squeeze Physicians Out Of Their Central Role In Health Care?

Not by a long shot if patients have anything to say about it.

Turns out that while most of us (90%) would like be able to make a doctor’s appointment and check lab results online….85% of us also still want the option of be able to talk to our physician face-to-face.  These are the finding from a recent 2012 study conducted by Accenture.

These finding will no doubt come as a surprise to many of those high tech newcomers to health care looking to make physician and trips to the doctor’s office a thing of the past with some new “killer health app.” You wouldn’t believe how little many of these software and app developers know about how health care works.  Then again, if you have looked at some of the EMRs, PHRs, and patient portals solutions being hyped out there maybe you could believe it.

What is significant about the finding cited above is that patients at least get it.  They understand the value of a having a relationship with a knowledgeable physician or similar health care provider.  In spite of, and for some, because of the plethora of health information outlets on the web people want to know that they always have access to your family doc when the chips are down.

What newbie software engineers and  smart phone app developers fail to understand is that health care is fundamentally about social interactions…not technical data transactions like depositing a check or making an airline reservation.

Here’s what I mean…based upon some 20+ years working in health care:

• From the get go…going back to Hippocrates…health and health care delivery has been about the relationships between people starting with the  physician-patient.relationship.

• The most important diagnostic tool a physician has at their disposal is not a smart phone…but their ability to talk with and observe  patients verbal and non-verbal behavior.

•  “Talk” is not only how physicians diagnose problems and recommend the appropriate treatments…talk is also how patients are able to engage in the health care.  Perhaps the most overlooked aspect of talk (and touch) during the medical exam is the therapeutic benefits patients derive from being able to express heart-felt fears and concerns to someone who hopefully cares.

The unfulfilled promises of so much of health information technology today (like Electronic Medical Records, Personal Health Records, and Patient Portals), with some notable exceptions like Kaiser, Group Health and the VA, can be traced directly back to developers not understanding that their job is to enable physician-patient relationships not get in their way or try and replace them.

Check out this related post – Patient Engagement Is A Physician-Patient Communication Challenge…Not A Health Information Technology Challenge

I don’t consider myself a Luddite when it comes to health information technology…nor would I put most physicians in this category.  The health industry is going through massive change, and unfortunately in such time, there is also a lot of false starts and waste that comes from ill conceived HIT solutions.  I suspect that tech vendors that take the time to learn the business that is health care, and commit themselves to improving the physician-patient relationship…will do just fine.

 The Take Away…

The physician-patient relationship remains paramount for us patients.  Yes there are problems…yes physicians and patient need to learn to do a better job communicating with one another.  But when everything is said and done…when the chips are down…we don’t want to be forced to diagnose and treat ourselves.  We want to be able to see and talk with our doctor when we want.  And honoring the patient’s perspective after all is what patient-centered care is all about right?

And oh by the way…we still want the convenience of being able to go online to schedule an appointment and check out lab tests.

That’s my opinion…what’s yours?

Sources:

Squeezing out the doctor -The role of physicians at the center of health care is under pressure.  The Economist. June 2012.

Could mobile apps replace doctors?  KevinMD.com