Based on an interview with Erica S. Spatz, MD, MHS,
Assistant Professor of Medicine, Yale School of Medicine
Imagine that you’re about to be wheeled into surgery. You’ve fasted for 24 hours, you’re in a hospital gown, and you’re awaiting the doctor’s arrival. Then the nurse brings in some paperwork, and you’re asked to sign a form acknowledging the risks of the procedure. You see some potential side effects or consequences that concern you—but at that point, how likely are you to refuse the procedure?
For many patients, that last-minute signature is the only experience they have with informed consent. Legally, however, informed consent is defined as the process in which a patient learns about and understands the purpose, benefits, and potential risks of a medical or surgical intervention.
In my view, that discussion should begin long before surgery day, so a patient has time to balance the risks and benefits before moving forward with a decision.
Recently, Care for Your Mind has been discussing shared decision making (SDM), a process through which patients and doctors make care choices together. SDM is poised to transform medical care; yet, nowhere is its potential benefit more clear than when it comes to improving the informed consent process.
As we shift towards a more patient-centric model of healthcare, widespread adoption of shared decision making — and a more thorough approach to informed consent—will benefit patients, physicians, and systems alike.
What’s happening in Washington State
The State of Washington has been the first to connect the dots between shared decision making and informed consent. Legislation was passed in 2007 that qualified SDM as a type of informed consent, meaning that any time informed consent is required, SDM — along with patient decision aids — could be used instead.
So why did the state make the move towards SDM? According to the Washington State Health Care Authority (HCA), “By encouraging the widespread use of certified decision aids by clinicians and patients in shared decision making, the State of Washington intends to promote patient engagement, improve health care quality, and reduce avoidable costs.”
One study showed that when patients were offered a decision aid for hip and knee osteoarthritis, hip and knee surgery rates sharply declined, thereby lowering costs. The study conclusions suggest that if patients have a better sense of the anticipated likelihood of benefit (or lack thereof) from a procedure or treatment, they may be more inclined to go with less invasive options.
Patients prefer SDM, and so should physicians and health systems
As Washington State has acknowledged, there’s no question that SDM is better for patients. Research shows that patients prefer shared decision making, they appreciate it, and it leaves them better able to participate in their own care. But it’s not just patients who benefit. SDM is better for physicians—and the entire healthcare system.
Consider any kind of medical malpractice case. In these lawsuits, plaintiffs claim that the physician failed to properly inform the patient. And while informed consent forms are supposed to protect medical professionals from this kind of litigation, ironically, they don’t hold up in a court of law. If a patient signed the form but never understood the information, the form is useless.
When clinicians engage in shared decision making, it affords them additional protection in the case of a lawsuit.
SDM can also help to bolster the patient-physician relationship. When physicians enable SDM they learn a lot more about their patients. They’re also forced to delve into the literature and learn more about procedures and outcomes. In the end, it creates more astute practitioners.
In addition, SDM may benefit health systems. With new pay-for-performance models, it is increasingly in the interests of health systems (and payors) to promote the appropriate use of technology and fewer unnecessary procedures, thereby improving patient safety and potentially lowering costs.
In one recent example, Medicare is now requiring some heart patients to see a second doctor before receiving a new medical device. The hope is that another opinion will help patients better assess their own values and preferences before they make a decision.
Decision aids make everything easier
In his recent CFYM post, John Williams, M.D., introduced the importance of decision aids when it comes to SDM. These content-rich tools come in many forms, are co-developed by patients and doctors, and offer a wealth of relevant information. The Mayo Clinic, for example, offers a statin decision aid. These are invaluable when it comes to helping patients assess their own values, goals, and preferences.
The Washington State HCA was the first in the nation to create a certification process for decision aids, and recently opened the floor to consider aids for acceptance. The National Quality Forum is also outlining a nationwide process to certify the quality of aids, which will insure a high standard. These tools should quickly become far more available in doctor’s offices nationwide.
How can we make shared decision making the norm?
As Washington state has shown, legislation can have a big impact. Changes in policy are huge and it would be ideal to see similar laws around shared decision making passed in all 50 states, or at the national level.
Incentives are another way to drive change. As our medical system starts moving from a fee-for-service to a pay-for-performance model, it makes sense that shared decision making should be rewarded. If providers are offered financial incentives for using decision aids and practicing SDM, they’re much more likely to do so.
For patients, if SDM isn’t already happening in your doctor’s office, the best way to initiate the process is by asking questions. Ask your doctor for resources to help you make a decision, ask for time to consider your options, ask about the specific risks and benefits related to your lifestyle. The more information you have, the better off you’ll be when it comes to making a decision.
There’s value to be derived across the board from SDM — and a broader definition of informed consent. Everyone needs to support the practice, from elected officials to providers to insurance companies. The system is increasingly moving towards patient-centric care, but in order to truly honor patient preferences, we have to create a culture where shared decision making is the norm.
Dr. Erica Spatz, MD, MHS
Dr. Erica Spatz is a general cardiologist and clinical investigator at the Center for Outcomes Research and Evaluation at Yale University School of Medicine. Her clinical and research interests include the development of individualized approaches to disease management, along with tools to help patients become more active in their healthcare decisions.