Care For Your Mind acknowledges and appreciates the collaboration of the National Network of Depression Centers in developing this post.
Juan P. Brito Campana, M.D, MSc.
Annie LeBlanc, Ph.D.
Mayo Clinic Knowledge and Evaluation Research Unit (KER)
As recent CFYM posts have indicated, shared decision making (SDM) is good for patients, doctors, and the system itself. But if we want SDM to become the norm in exam rooms nationwide, we have to support clinicians by giving them the means to make it happen.
We can do this by providing tools that allow physicians to communicate effectively and engage in meaningful conversations about their patients’ preferences, needs, and values.
In addition to time and training, well designed conversation tools can help doctors to better communicate with patients. At the Mayo Clinic for the last 10 years, we have developed and made available these tools, sometimes called decision aids, to support the practice of SDM.
Of course, decision aids are not sufficient (and may not be necessary in every situation) to promote SDM, but effective ones could really help SDM become more feasible.
What makes for an effective decision aid?
Because every healthcare choice involves different considerations, every decision aid is completely unique.
First, our team summarizes the best available evidence surrounding any given issue. We do systematic reviews and videotape doctor-patient encounters to determine which information is most important to patients. Then, we develop the aids, typically using pictograms (instead of numbers and percentages) that allow patients to see the data in a more visual way. Lastly, we test prototype aids in actual patient-clinician encounters.
So how do we measure their effectiveness? Admittedly, it’s tricky. If the clinicians use the decision aids and the conversation flows, we generally consider the aid a success. If they put the aid aside or it doesn’t improve doctor-patient communication, we head back to the drawing board.
Overall, we look for signs of engagement: body language, patient response, length of conversation, etc. Having videotaped thousands of encounters, we’ve developed a pretty good understanding of whether an aid is doing its job. A key marker is the ability of the patient to try the treatment options on for size and fit, like clothes at a shop. Patients may ask questions or make statements to that effect: “So if I do X now, I may be able to do Y later?” At this point, we have an array of effective aids for different scenarios, including depression medication, diabetes medication, statin choice, and many others.
In terms of clinical outcomes, it’s challenging to measure the value of these aids. We don’t expect depression severity to decrease with the use of a medication decision aid, for example, but it can help a patient find the best drug for their personal circumstance—and feel more confident about their choice. It may follow (although the evidence is not yet in) that when patients select their approach, it is more likely to fit their context and preferences, thereby enhancing adherence, and therefore effectiveness. This, of course, would not be a benefit of the patient using the decision aid, but of the SDM conversation supported by that tool.
Easy to use and no training required
What’s unique about Mayo’s decision aids is that they’re designed to be picked up and used by any clinician, at any time. There’s no training necessary; the aids make the process as easy as possible.
Take our depression medication aid. While primary care physicians handle the majority of depression cases in this country, most have a thorough knowledge of only two or three depression medications. With our decision aid, they’re able to see what the other options are and help offer patients a greater number of appropriate choices, plus the pros and cons of each. This empowers clinicians to help their patients consider a broader array of options than they’d normally be offered in a traditional primary care visit.
It’s also essential that doctors are on board with the content of the decision aids. SDM is a two-way street and clinicians play a key role in this process. The tools have to take their needs and opinions into account. If doctors don’t see the value, they’re unlikely to use the aids. If the tools are properly designed in consultation with practicing clinicians, it is more likely that clinicians will find using the tools worthwhile. Hence, why we design and test our tools in usual clinical encounters to make sure they’re useful to both doctors and patients.
Some people argue that using decision aids and SDM can lead to patients choosing more expensive treatment options, thereby putting more stress on the healthcare system. Others have put forward the opposite argument, that is, that SDM can reduce utilization of expensive options and overall cost; this is the view reflected in the Affordable Care Act provision supporting SDM (Section 936). SDM, however, allows for cost to be a part of the conversation. Doctors and patients can discuss the risks, preferences, benefits, and costs as part of the process.
That being said, it’s important to note that it’s not the doctor’s job to make sure the patient chooses the cheapest care — it’s his or her job to make sure the patient gets the best care, the care that addresses their situation in an evidence-based manner that reflects their values and informed preferences. Policymakers are responsible for addressing cost concerns and the larger needs of society.
While there is evidence that SDM has inconsistent effects on healthcare utilization and costs, it’s worth noting that decision aids might actually make the treatment process more efficient. Certainly it takes more time to implement SDM in an initial visit but, following that, the doctor and patient may have laid the groundwork for quicker follow-up care.
With depression, for example, once a patient has seen the decision aid, he or she will be educated on the different medication options. From there, a follow-up visit to solve the problem of intolerance or inefficacy of a drug could be quickly addressed by revisiting the tool. We don’t have enough data — yet — to say for sure that aids increase efficiency, but we suspect the evidence will bear that out.
Despite providing tools and having doctors who are willing to use them, we’ll never be able to implement SDM if we don’t change what happens around a doctor-patient encounter.
The system has to provide a platform where these conversations can happen. One example of the current problem lies with one of our champion practices, located in Duluth, Minnesota. Primary care clinicians there use our statin decision aid often. But because patients and clinicians often decide that statins are not right for the patient (despite guideline recommendations in the contrary), doctors must spend time and effort defending these decisions.
In other words, patients choosing not to take statins can negatively affect the performance measures of their doctors and clinics. (In Minnesota these measures are reported publicly.) But a doctor or clinic should never be penalized for the results of an evidence-based patient-centered process.
It’s unacceptable that the health system is set up in a way that keeps doctors from doing what’s right for their patients. This has to change at the policy level if we ever hope to see a widespread improvement in care.
Investments that enable the implementation of SDM may support a practice in achieving its goals of delivering care that is of high quality, efficient, and responsive to patient needs and preferences. This may include the formalization of SDM visits (using a billing code for SDM, for example), allowing adequate time for clarifying the patient situation, discussing the options and their pros and cons using an efficient decision aid, and deliberating until a solution to the situation emerges and a plan for implementation is formulated.
In all, we have to continue advocating for patient-centered care, training of clinicians and patients for mutual engagement, development of evidence-based and effective decision aids, and systematically removing policy and health care organizational barriers that interfere with meaningful doctor-patient conversations. Only then will we see shared decision-making become the standard of care.
- What has been your experience with shared decision making and the use of decision aids?
- What do you like about the idea of decision aids? What do you not like about them?
Juan P. Brito Campana. M.D, MSc., is an endocrinologist, health care delivery researcher and principal investigator in the Knowledge and Evaluation Research Unit (KER) and Medical Director of Mayo Clinic Shared Decision Making National Resource Center, Mayo Clinic, Rochester, MN, United States. Email: Brito.email@example.com. Twitter: @doctorjuanpa
Dr. Annie LeBlanc, PhD is Associate Professor within the Department of Family and Emergency Medicine, Faculty of Medicine, Laval University, Quebec, Canada, Co-Director of the Knowledge Translation Core, Strategy for Patient Oriented Research (SPOR) Quebec SUPPORT Unit, and investigator within the CHU Quebec Research Center, the Quebec Institute of Primary Healthcare and Social Services, and the Mayo Clinic Knowledge and Evaluation Research (KER) Unit (Minnesota, USA). Her research centers around the translation of comparative effectiveness research (CER) into practice through the design, evaluation, implementation, and sustainability of patient-centered interventions, such as shared decision making, and their impact on patient important outcomes. Dr. LeBlanc is a well-published author who has led or contributed to more than 10 clinical trials of shared decision making in primary and specialty care settings across 3 Countries. She now lives in Quebec City (Quebec, Canada) with her husband and two children. Email:Annie.firstname.lastname@example.org. Twitter: @annie_leblanc