Tag Archives: patient-centered care

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).

Pinnicle of patient-centered communications

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

AdoptOneBigButtonThe 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.

What Are Your Personal Health Goals? Have You Ever Shared Them With Your Doctor? Has Your Doctor Ever Asked You What Yours Are?

Face it.  We all have personal health goals.  We may not share our personal health goals with family of friends like we do our financial or professional goals, but we all still have them.   I for example aspire to the following personal health goals:

  • To defy the conventional wisdom associated with aging (look younger, feel younger, live like I am younger).
  • To avoid premature aging – vision problems, flexibility and balance issues, aging and appearance, weight gain, skin tone, etc.
  • To not be called old by my grand kids
  • To live a more active life than my parents did
  • Question authority (yes I am a product of the 60’s and 70’s)

OK personal health goalsso I am vain.  I bet I am not the only one.  I am just the one dumb enough to publicly admit it (LOL).

Have I ever share these goals with my doctor?  Are you kidding me?

He can’t deal with the fact that I experience depression from time to time and insist on telling him about it…eeewww.   Besides…he will just tell me that getting old is part of the natural process.   You are supposed to lose your hearing, lose your balance and flexibility, get fat and wrinkly, become senile, and so on.   Let’s face it. It’s hard to have a conversation with someone – including your physician – when you know from experience that they are simply not interested  in what you have to say…or don’t share your point of view…when it comes to certain subjects.

There’s also another reason I have never shared my person health goals with my physician.   I have never been asked.

In their defense, doctors aren’t trained to care about things beyond the realm of strict biomedical conditions – acute conditions in other words.   That’s why it is so hard for physicians and many other provider types to get their heads around patient-centered care.   To become more patient-centered providers need to deal with touchy feely issues like personal health goals, personal health beliefs and motivations, family issues, depression, anxiety and all the other human emotions.   A physician I know referred to patient-centered care as a kind of “rabbit hole” physicians just don’t want to go down.  Getting to know the “person behind the disease” is time consuming and can take you down paths you not sure where they end up!

Health care executives, providers and payers wonder why patients aren’t more engaged in their health…aka do as they are told.  The problem isn’t that patients (people) aren’t engaged in their health…they are…the problem is that so much of what is passed off as patient engagement these days (EHRs, PHRs, team care, care coordinators, web portals, decision support tools) are not inherently engaging to us patients!   Why?  Go back and read my personal health goals and explain to how today’s technology-enabled vision of patient engagement is at all relevant to my (and I suspect many of your) personal health care goals.   

That’s what I think.   What’s your opinion?

Post Script

As I mentioned in my last post, I am heading up a research team that will be auditing 2,500 physician-patient conversations recorded during primary care office visits from across the US.   Among the many questions we will seek to answer will be the frequency with which physicians and/or patients raise the question of the patient’s personal health goals.

Stay tuned.  For more information on the 2012 Physician-Patient Communication Benchmark Report click here.

Patient-Centered Care – We Aren’t Ready for It

The follow is a guest post by Aanand D. Naik, MD  @empoweringpts.

We hear lots of discussion nowadays about Patient-Centered Care.  Most legislation for health care reform proposes innovative models of care such as Accountable Care Organizations and the Patient-Centered Medical Home (PCMH) with “Patient-Centered Care” at the core.  Given all the attention: Who could possibly be against Patient-Centered Care?

In this wake, I forward the controversial contention that many patients, probably a majority of health care providers, and every major health plan and health insurer really doesn’t believe in Patient-Centered Care.  Or at the very least, they aren’t ready to change the basic paradigms of health care to cultivate what Patient-Centered Care truly is and what its requires.  Simply put, we aren’t ready for Patient-Centered Care.

To clarify my argument, a clear understanding of Patient-Centered Care is needed.  The first consensus definition comes from the 2001 Institute of Medicine Report, Crossing the Quality Chasm.   The IOM report defines Patient-Centeredness as, “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.”  The report clarifies several principles of health system redesign that will better align health care along 6 quality dimensions.  The principles most closely tied to the dimension of Patient-Centeredness include: a) customization of care based on patient needs and values; b) the patient as the source of control; c) shared knowledge and the free flow of information, and d) the need for transparency.

When fully realized, these are powerful principles–they can and will transform health care.  But, they must all occur together to ensure that transformation happens.  If only one or two of these principles are accomplished, especially if only the principles of free flow of knowledge and customization based on patient-need; then there will be little positive change at all.

Don Berwick wrote a wonderful essay in Health Affairs in 2009  in which he describes the lively debate that occurred on the IOM panel that defined Patient-Centered Care.  He defends the “extremist” position and adds his own parameters for patient centeredness: (1) “The needs of the patient come first.”(2) “Nothing about me without me.”(3) “Every patient is the only patient.”   These are compelling additions to the original IOM definition.  What I fear is that without the coexisting principles of transparency and patient control, the “needs of the patients” will be defined by doctors, providers, hospitals, health systems, and insurers rather than patients themselves.

My further belief is that the types of reforms gaining momentum, like PCMH, will actually precipitate and worsen the problems of supply-driven demand and hyperinflation because they will simply increase patients’ acceptance of doctors’ recommendations through “free flow of information and knowledge” and enhanced patient-centered communication.

Without truly making information transparent and giving patients real control of the ends and means of health care, then it’s simply patient-friendly talk and involvement in discussions related to what the doctor thinks is best.

Transparency is more than the free flow of information and patient-centered communication.  Transparency occurs when patients understand “in their gut” the meaning of the health problem and how health care will impact their daily lives.  Patients have control when they choose not to pursue a course of action the doctor might recommend because those outcomes are not consistent with their values or the desired course of their lives.  In the non-transparent form of PCMH, access to health care improves but health costs will continue to skyrocket.

What we need now is real discussion of patient control and transparency rather than platitudes about Patient-Centered Care.  What does it mean to give patients control and can control be helpful and lead to health outcomes that are consistent with our needs and values?  What does transparency really mean?  I wish Steve Jobs was still around to teach us a thing or two about the importance of design and the patient-interface in health care.  As a physician, I know the patient-doctor encounter is sacred and the doctor’s role is indispensible; but I am also fully ready to embrace transparency and patient-control over the ends and means of their health.

Aanand D. Naik is a medical geriatrician and health services researcher at the Michael E. Debakey VA Medical Center and Baylor College of Medicine in Houston, Texas.  Follow him on twitter @empoweringpts  The views expressed here have not been endorsed by either institution.

Sources:

Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001, National Academy Press, Washington, D.C.

Berwick, Donald. What “Patient-Centered” Should Mean: Confessions of an Extremist. Health Affairs. 2009, 28:w555-w565.