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.

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.

Improving The Way Doctors And Patients Communicate – A Silver Bullet For Fixing What’s Wrong With Health Care?

Sometimes a picture is worth a thousand words…

Five Myths About Empowered Patients Or E-Patients

Irrational exuberance was a term once used to describe the stock market before the last crash.  It also seems an apt description for much of the talk these days about empowered health consumers.

To be sure, patients today have unprecedented access to health information.  Patient decision-support tool can be found on just about every provider, payer and self-insured employer website.  Consumers can go to any number of websites to find quality data about hospitals, physicians and health plans.  Personal health records (PHRs) promise to make our personal health data portable for meaning that all our treating physicians will be “singing off the same song sheet.”

That’s what the industry experts tell us.  But what’s really going on?  Here I will describe what I see as the top 5 myths about empowered health consumers.

Myth #1 – All Patients Are Empowered or Becoming Empowered

Since pre-internet days (early 1990s), health behavior research has shown that about one third of adults desire above average health, one third are satisfied with average health, and one third don’t care one way or another.   Not surprisingly there is a direct correlation between one’s health aspirations and the degree to which one engages in activities typically associated with “empowerment, i.e., health information- seeking, exercise and good nutrition, and so on.   For example, people who place a low priority on health related activities for example often have an external locus of control.  This means that they don’t believe they can do anything to change their health destiny.

Using health information-seeking as a proxy for empowerment, it does not appear that people are significantly more inclined to seek health information today than they did during pre-internet days.

Myth #2 – Most Patients Choose To Be Empowered

Are patient empowered because they want to be or because they are forced to be out of necessity?  It is noteworthy that much of the research on patient empowerment comes from research pioneered by the National Cancer Institute.   This suggests a causal relationship between one’s condition (cancer) and how one reacts to it (information-seeking).  This trend subsequently spread from cancer care to all health care as physicians started to increasingly delegate health responsibilities to patients…without asking them, telling them or teaching them how to engage in these responsibilities.   Just ask any primary care physician involved in a medical home conversion.  Anecdotal evidence suggests that a good number of patients, when told of their new personal health responsibilities, respond by tell the doctor that “that’s your job.”

To be sure, a fair number of patients have become quite competent at managing their own health.  But it would be a mistake to assume that everyone is equally predisposed or capable of doing so.

Myth #3 – Health Information-Seeking Equal Empowerment  

Almost 80% of adults go online to seek health information according to the Pew Institute.   There is a tacit assumption in health care that information- seeking is synonymous with empowerment.  Yet information alone is not enough to change a person’s health behaviors, i.e., make them empowered, according to leading health care experts like Thomas Bodenheimer, MD, self care management guru Kate Lorig, and others.  Factors such as the person’s skills, self confidence and knowledge of how to navigate the health system are also important pre-requisites of behavior change.

It is worth noting that for some people; too much information can be disempowering resulting in too many choices and decisions.

Myth #4 – An Empowered Patient Trumps The Doctor

Nothing shuts down an empowered patient any faster than a physician who is short on time and communicates with patients using a physician-directed communications style (versus patient-centered).   As it is, the medical exam process does not afford patient much of an opportunity to speak without interruption.  As such most patients, including empowered patients, ask very few important questions.

Anecdotal evidence suggests that the longer one waits in the office to see the doctor, patients are moved to ask fewer questions in the interest of the doctor’s time.

Myth # 5 – Empowered Patient Are At Odds With Their Doctor

Empowered or not, patients and their doctors disagree on a fair number of important issues including reason for the visit, diagnosis, treatment options, amount of information desired, communication preferences and so on.  So disagreements are probably not the cause of the impression that being empowered equates to be obnoxious.   Rather the trick for the most empowered among us is to be able to disagree without being disagreeable.

That’s my opinion…what’s your?

Sources:

Wilkins, S. et al. A New Perspective on Consumer Health Web Use: “Valuegraphic” Profile of Health Information Seekers. Managed Care Quarterly. Vol 9, No. 2, 2001.

Bodenheimer, T. A 63-Year-Old Man With Multiple Cardiovascular Risk Factors and Poor Adherence to Treatment Plans.  JAMA. 2007;298(17):2048-2055.

Does Physician Denial Of Patient Requests Result In Decreased Patient Satisfaction?

The short answer: No.
 
At least not in the context of a strong physician-patient relationship.
 
Many physicians have legitimate concerns about the prospects of having their salary or level reimbursement linked to patient satisfaction. I would too given the way most health care providers go about measuring and interpreting patient satisfaction data.
 
A major concern of physicians is the issue of patient requests – particularly the impact of unfulfilled (and unreasonable) requests upon patient satisfaction. According to researchers, explicit patient requests for medications, diagnostic tests and specialty referrals occur in between 25% to 40% of primary care visits. This figure is much higher when requests for information are factored in.
 
In studies, primary care physicians accommodate patient requests for medications and diagnostic tests approximately 75% of the time. Physicians however accommodated only 40% of specialist referral requests. Physicians negotiated alternatives solutions to patient requests 22% of the time and denied patient requests the remaining 3% of the time. Information requests were met approximately 95% of the time by physicians.
 
Denial Of Patient Requests Has Little Impact On Patient Satisfaction
 
It is not at all clear from the research that physician denial of patient requests for medications, tests or specialist referrals has any negative effect on patient satisfaction. In the studies referenced here, little to no association was found between unfulfilled patient requests and patient satisfaction.
 
The one exception to this finding is where physicians fail to meet patient requests for health information. In such instances patient satisfaction was lower. This is not surprising when one study categorized the quality of physician responses to patient information requests as follows:
 

• 32% were of requests were fulfilled with a “terse” physician response
• 33% percent were fulfilled with an “intermediate” response
• 32% percent with an “elaborate” response.

 
Experts Advise Negotiating Patients Requests
 
It has been said that clinical encounters such as occur during office visits involve a “process of negotiation between the clinician and patient.” As such, physicians are advised to use the influence accorded them by their patients to help them understand the pros and cons of their request so as to negotiate actions are really needed.
 
Physicians that are truly concerned about their patient satisfaction score are better served by looking after the quality of their patient communications skills.
 
Sources:

Kravitz RL, Bell R a, Franz CE, et al. Characterizing patient requests and physician responses in office practice. Health Services Research. 2002;37(1):217-38.

Kravitz RL, Bell R a, Azari R, et al. Direct observation of requests for clinical services in office practice: what do patients want and do they get it? Archives of Internal Medicine. 2003;163(14):1673-81.

Peck BM, Asch DA, Goold SD, et al. Measuring Patient Expectations – Does the Instrument Affect Satisfaction or Expectations? Medical Care, Vol. 39, No. 1 pp. 100-108.

Keitz S a, Stechuchak KM, Grambow SC, Koropchak CM, Tulsky J. Behind closed doors: management of patient expectations in primary care practices. Archives of Internal Medicine. 2007;167(5):445-52.