Patient Education and Counseling 97 (2014) 145–146
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Editorial
What’s in shared decision-making for the physician?
The last decades have seen incredible developments in medicine. My 40-year old uncle, my father’s beloved little brother, died from cardiomyopathia in 1964. When his son, who was six, then acquired the same disease in 1998, he got a heart transplant and still lives well seventeen years later. What that means to his children is easy to imagine. The decision to accept a transplant was not difficult for him. Contrary to his father, he had an option. Sometimes, decisions are easy. But often they are not. There are countless conditions where there is no one single self-evident choice of treatment. Sometimes, options are equally likely to improve the patient’s health, but usually one treatment seems to stand a better chance of generating a satisfactory result. However, the expected outcome carries a varying degree of uncertainty, and side effects lurk. Besides, the treatment may imply risks that could be acceptable for some patients, but not for others. And my cousin could have had a religious belief that would lead him to face an intolerable dilemma: which values are most important to me? Such deliberations have fostered the inclusion of shared decision-making as one important and integral part of patient-centred medicine, a certain way of meeting patients that is built on an ethical imperative [1]. Shared decision-making seemed such a wonderful idea. The slogan ‘‘Nothing about me without me’’ [2] has been well received by patient organizations and politicians. Its message forms the basis for patient rights laws and regulations in several countries. But is it so clear? Although the literature is quite unanimous that patients prefer to be informed, studies are more mixed in conclusions about the effects of patient-centred care and shared decision-making on outcomes [3–7] and the effectiveness of interventions to make clinicians change behaviour [8,9]. This could be because the study methods are not yet up to the challenge: it is truly difficult to disentangle the specific effects of physician behaviour on later outcomes. Another possibility is that we are still far from understanding the complexity of information exchange and shared decision-making in medical encounters. We might expect a diversity of outcomes depending on the clinical condition, on other characteristics or skills of the physician besides patient-centred behaviour, and certainly on patient characteristics and preferences. So initiatives to develop new theory in the field, as Elwyn et al. demonstrate in an article on a model they refer to as ‘‘Collaborative deliberation’’ in the present issue of PEC [10], are very welcome. The authors point out that existing theoretical work in decision making and behaviour change has focused too much on the intraindividual processes of the participants and less on the collaborative process between them. Certainly, conversations as collaborative processes have been demonstrated outside http://dx.doi.org/10.1016/j.pec.2014.09.001 0738-3991/ß 2014 Elsevier Ireland Ltd. All rights reserved.
medicine [11]. But obstacles against achieving such a conversation in medicine may be greater than elsewhere in society, which may explain why collaborative deliberation in decision-making about diagnosis and treatment is still not the rule. On the patient’s side, it is not that they do not want to be informed and empowered. Patients use a range of subtle communication strategies to gain power when they talk with physicians [12]. However, during shared decision-making, discussions about effects and risks are inevitable, and physicians’ knowledge in this domain and power to do something about it are important factors in gaining patients’ trust in the physician in the first place [13]. If the physician’s initiation of shared decision-making is just a bit awkward, the whole responsibility balance may shift, inducing a loss of trust. Physicians who accept new regulations, and who are motivated to try out shared decision-making, but who lack training, could easily end up perceiving unfavourable patient reactions, leading them to dismiss the concept. Such experiences could fuel resistance among physicians. In a 2008 review, Le´gare´ and colleagues presented a long list of health providers’ reported barriers to the implementation of shared decision-making [14]. The time-consuming nature of the process was mentioned in two thirds of the reviewed studies. Other oftenmentioned barriers were specific problems related to the clinical situation and the characteristics of the patient, including lack of preference to be involved. Much resistance was due to lack of agreement about aspects of shared decision-making, including interpretation of the evidence. In several studies, lack of physician self-efficacy, complexity, and familiarity with the model were identified. Other possibly influential barriers were lack of reimbursement, perceived risk of increased liability, concerns about clarity of responsibility for the treatment, rigid procedures, and physician autonomy. We see a broad range of reasons for not applying shared decision-making in practice. Facilitators, which were fewer, were mostly a strong motivation and expectancy of favourable outcomes. Some societal changes could promote physicians’ willingness to try shared decision-making. First, there is the strong increase in the number of patients who approach their physician with information acquired via the internet [15], sometimes a source of hassle and annoyance. Second, physicians are increasingly experiencing complaints [16], which are often about patients not being informed about unexpected outcomes or side effects. This tends to lead to frustration: handling complaints takes time, as does back-covering measures like meticulous notes in patient records about what kind of information was provided. However, as just a minority of encounters eventually lead to a complaint, physicians are not likely to see the connection with their practice, although such
146
Editorial / Patient Education and Counseling 97 (2014) 145–146
associations have been demonstrated [17,18]. Instead, among physicians, complaints about patients not listening to them and not remembering what was said are ubiquitous. This is, of course, a defensive reaction, but we should remember that physicians, like patients, need to take care of themselves. They are not necessarily happy with time-consuming discussions that often seem only to complicate visits and leave both parties confused [19]. While skilled physicians may experience shared decision-making as a good investment in their own practice because it leads to fewer clarifying phone calls, better adherence, and less need for repeated explanations or changes of treatment strategy, staff physicians in a busy hospital environment may not see this improvement. The extra time used may fall as a burden upon them, while the gains are distributed on the whole system. Hence, there is a missing link in most countries, and that is system measures to induce change. Thorough theory development by researchers, and laws and regulations that enforce patients’ rights are not enough. Health authorities, institutional management, and medical communities should accept the complex nature of the collaborative deliberations in medicine, and this should lead to provision and funding for sufficient training nationwide. Unless society links the value shared decisionmaking represents for people to effective training, there is no reason to believe that physicians will be tempted to change their behaviour. They are, after all, accustomed to being accepted as trustworthy, beneficial, powerful, knowledgeable, by their (mostly) acquiescent patients. References [1] Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th ed. Oxford: Oxford University Press; 2001. [2] Delbanco T, Berwick DM, Boufford JI, et al. Healthcare in a land called PeoplePower: nothing about me without me. Health Expect 2001;4(3):144–50. [3] Duncan E, Best C, Hagen S. Shared decision making interventions for people with mental health conditions. Cochrane Database Syst Rev 2010;(Issue 1): CD007297. [4] Coyne I, O’Mathu´na DP, Gibson F, et al. Interventions for participation in shared decision-making for children with cancer. Cochrane Database Syst Rev 2013;(Issue 6):CD008970.
[5] Horey D, Kealy M, Davey M-A, et al. Interventions for supporting women’s decision-making about mode of birth after a caesarean. Cochrane Database Syst Rev 2013;(Issue 7):CD010041. [6] Barbui C, Girlanda F, Ay E, et al. Implementation of treatment guidelines for specialist mental health care. Cochrane Database Syst Rev 2014;(Issue 1): CD009780. [7] Schedlbauer A, Davies P, Fahey T. Interventions to improve adherence to lipid lowering medication. Cochrane Database Syst Rev 2010;(Issue 3):CD004371. [8] Le´gare´ F, Ratte´ S, Stacey D, et al. Interventions for improving the adoption of shared decision making by healthcare professionals. Cochrane Database Syst Rev 2010;(Issue 5):CD006732. [9] Dwamena F, Holmes-Rovner M, Gaulden CM, et al. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev 2012;(Issue 12):CD003267. [10] Elwyn G, Lloyd A, May C, et al. Collaborative deliberation: a model for patient care. Patient Educ Couns 2014;97:158–64. [11] Isaacs EA, Clark HH. References in conversation between experts and novices. J Exp Psychol 1987;116(1):26–37. [12] Ainsworth-Vaughn N. Patients claiming power in doctor-patient talk. Oxford: Oxford University Press; 1998, Studies in Sociolinguistics. [13] Grimen H. Power, trust, and risk: some reflections on an absent issue. Med Anthropol Q 2009;23:16–33. [14] Le´gare´ F, Ratte´ S, Gravel K, et al. Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals’ perceptions. Patient Educ Couns 2008;73:526–35. [15] Tate P, Tate L. The doctor’s communication handbook. 7th ed. London: Radcliffe; 2014. [16] Moberly T. Rising complaints against doctors due to changed patient expectations, researchers say. Brit Med J 2014;349:g4754. [17] Levinson W, Roter DL, Mullooly JP, et al. Physician–patient communication. The relationship with malpractice claims among primary care physicians and surgeons. J Amer Med Assoc 1997;277:553–9. [18] Tamblyn R, Abrahamowicz M, Dauphinee D, et al. Physician scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities. J Amer Med Assoc 2007;298:993–1001. [19] Gulbrandsen P, Dalby AM, Ofstad EH, et al. Confusion in and about shared decision making in hospital encounters. Patient Educ Couns 2014;96: 287–94.
Pa˚l Gulbrandsen* Professor, Institute of Clinical Medicine, University of Oslo, and Akershus University Hospital, Sykehusveien 25, 1478 Lørenskog, Norway *Tel.: +47 6796 8718 E-mail addresses: [email protected], [email protected]
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Editorial
What’s in shared decision-making for the physician?
The last decades have seen incredible developments in medicine. My 40-year old uncle, my father’s beloved little brother, died from cardiomyopathia in 1964. When his son, who was six, then acquired the same disease in 1998, he got a heart transplant and still lives well seventeen years later. What that means to his children is easy to imagine. The decision to accept a transplant was not difficult for him. Contrary to his father, he had an option. Sometimes, decisions are easy. But often they are not. There are countless conditions where there is no one single self-evident choice of treatment. Sometimes, options are equally likely to improve the patient’s health, but usually one treatment seems to stand a better chance of generating a satisfactory result. However, the expected outcome carries a varying degree of uncertainty, and side effects lurk. Besides, the treatment may imply risks that could be acceptable for some patients, but not for others. And my cousin could have had a religious belief that would lead him to face an intolerable dilemma: which values are most important to me? Such deliberations have fostered the inclusion of shared decision-making as one important and integral part of patient-centred medicine, a certain way of meeting patients that is built on an ethical imperative [1]. Shared decision-making seemed such a wonderful idea. The slogan ‘‘Nothing about me without me’’ [2] has been well received by patient organizations and politicians. Its message forms the basis for patient rights laws and regulations in several countries. But is it so clear? Although the literature is quite unanimous that patients prefer to be informed, studies are more mixed in conclusions about the effects of patient-centred care and shared decision-making on outcomes [3–7] and the effectiveness of interventions to make clinicians change behaviour [8,9]. This could be because the study methods are not yet up to the challenge: it is truly difficult to disentangle the specific effects of physician behaviour on later outcomes. Another possibility is that we are still far from understanding the complexity of information exchange and shared decision-making in medical encounters. We might expect a diversity of outcomes depending on the clinical condition, on other characteristics or skills of the physician besides patient-centred behaviour, and certainly on patient characteristics and preferences. So initiatives to develop new theory in the field, as Elwyn et al. demonstrate in an article on a model they refer to as ‘‘Collaborative deliberation’’ in the present issue of PEC [10], are very welcome. The authors point out that existing theoretical work in decision making and behaviour change has focused too much on the intraindividual processes of the participants and less on the collaborative process between them. Certainly, conversations as collaborative processes have been demonstrated outside http://dx.doi.org/10.1016/j.pec.2014.09.001 0738-3991/ß 2014 Elsevier Ireland Ltd. All rights reserved.
medicine [11]. But obstacles against achieving such a conversation in medicine may be greater than elsewhere in society, which may explain why collaborative deliberation in decision-making about diagnosis and treatment is still not the rule. On the patient’s side, it is not that they do not want to be informed and empowered. Patients use a range of subtle communication strategies to gain power when they talk with physicians [12]. However, during shared decision-making, discussions about effects and risks are inevitable, and physicians’ knowledge in this domain and power to do something about it are important factors in gaining patients’ trust in the physician in the first place [13]. If the physician’s initiation of shared decision-making is just a bit awkward, the whole responsibility balance may shift, inducing a loss of trust. Physicians who accept new regulations, and who are motivated to try out shared decision-making, but who lack training, could easily end up perceiving unfavourable patient reactions, leading them to dismiss the concept. Such experiences could fuel resistance among physicians. In a 2008 review, Le´gare´ and colleagues presented a long list of health providers’ reported barriers to the implementation of shared decision-making [14]. The time-consuming nature of the process was mentioned in two thirds of the reviewed studies. Other oftenmentioned barriers were specific problems related to the clinical situation and the characteristics of the patient, including lack of preference to be involved. Much resistance was due to lack of agreement about aspects of shared decision-making, including interpretation of the evidence. In several studies, lack of physician self-efficacy, complexity, and familiarity with the model were identified. Other possibly influential barriers were lack of reimbursement, perceived risk of increased liability, concerns about clarity of responsibility for the treatment, rigid procedures, and physician autonomy. We see a broad range of reasons for not applying shared decision-making in practice. Facilitators, which were fewer, were mostly a strong motivation and expectancy of favourable outcomes. Some societal changes could promote physicians’ willingness to try shared decision-making. First, there is the strong increase in the number of patients who approach their physician with information acquired via the internet [15], sometimes a source of hassle and annoyance. Second, physicians are increasingly experiencing complaints [16], which are often about patients not being informed about unexpected outcomes or side effects. This tends to lead to frustration: handling complaints takes time, as does back-covering measures like meticulous notes in patient records about what kind of information was provided. However, as just a minority of encounters eventually lead to a complaint, physicians are not likely to see the connection with their practice, although such
146
Editorial / Patient Education and Counseling 97 (2014) 145–146
associations have been demonstrated [17,18]. Instead, among physicians, complaints about patients not listening to them and not remembering what was said are ubiquitous. This is, of course, a defensive reaction, but we should remember that physicians, like patients, need to take care of themselves. They are not necessarily happy with time-consuming discussions that often seem only to complicate visits and leave both parties confused [19]. While skilled physicians may experience shared decision-making as a good investment in their own practice because it leads to fewer clarifying phone calls, better adherence, and less need for repeated explanations or changes of treatment strategy, staff physicians in a busy hospital environment may not see this improvement. The extra time used may fall as a burden upon them, while the gains are distributed on the whole system. Hence, there is a missing link in most countries, and that is system measures to induce change. Thorough theory development by researchers, and laws and regulations that enforce patients’ rights are not enough. Health authorities, institutional management, and medical communities should accept the complex nature of the collaborative deliberations in medicine, and this should lead to provision and funding for sufficient training nationwide. Unless society links the value shared decisionmaking represents for people to effective training, there is no reason to believe that physicians will be tempted to change their behaviour. They are, after all, accustomed to being accepted as trustworthy, beneficial, powerful, knowledgeable, by their (mostly) acquiescent patients. References [1] Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th ed. Oxford: Oxford University Press; 2001. [2] Delbanco T, Berwick DM, Boufford JI, et al. Healthcare in a land called PeoplePower: nothing about me without me. Health Expect 2001;4(3):144–50. [3] Duncan E, Best C, Hagen S. Shared decision making interventions for people with mental health conditions. Cochrane Database Syst Rev 2010;(Issue 1): CD007297. [4] Coyne I, O’Mathu´na DP, Gibson F, et al. Interventions for participation in shared decision-making for children with cancer. Cochrane Database Syst Rev 2013;(Issue 6):CD008970.
[5] Horey D, Kealy M, Davey M-A, et al. Interventions for supporting women’s decision-making about mode of birth after a caesarean. Cochrane Database Syst Rev 2013;(Issue 7):CD010041. [6] Barbui C, Girlanda F, Ay E, et al. Implementation of treatment guidelines for specialist mental health care. Cochrane Database Syst Rev 2014;(Issue 1): CD009780. [7] Schedlbauer A, Davies P, Fahey T. Interventions to improve adherence to lipid lowering medication. Cochrane Database Syst Rev 2010;(Issue 3):CD004371. [8] Le´gare´ F, Ratte´ S, Stacey D, et al. Interventions for improving the adoption of shared decision making by healthcare professionals. Cochrane Database Syst Rev 2010;(Issue 5):CD006732. [9] Dwamena F, Holmes-Rovner M, Gaulden CM, et al. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev 2012;(Issue 12):CD003267. [10] Elwyn G, Lloyd A, May C, et al. Collaborative deliberation: a model for patient care. Patient Educ Couns 2014;97:158–64. [11] Isaacs EA, Clark HH. References in conversation between experts and novices. J Exp Psychol 1987;116(1):26–37. [12] Ainsworth-Vaughn N. Patients claiming power in doctor-patient talk. Oxford: Oxford University Press; 1998, Studies in Sociolinguistics. [13] Grimen H. Power, trust, and risk: some reflections on an absent issue. Med Anthropol Q 2009;23:16–33. [14] Le´gare´ F, Ratte´ S, Gravel K, et al. Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals’ perceptions. Patient Educ Couns 2008;73:526–35. [15] Tate P, Tate L. The doctor’s communication handbook. 7th ed. London: Radcliffe; 2014. [16] Moberly T. Rising complaints against doctors due to changed patient expectations, researchers say. Brit Med J 2014;349:g4754. [17] Levinson W, Roter DL, Mullooly JP, et al. Physician–patient communication. The relationship with malpractice claims among primary care physicians and surgeons. J Amer Med Assoc 1997;277:553–9. [18] Tamblyn R, Abrahamowicz M, Dauphinee D, et al. Physician scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities. J Amer Med Assoc 2007;298:993–1001. [19] Gulbrandsen P, Dalby AM, Ofstad EH, et al. Confusion in and about shared decision making in hospital encounters. Patient Educ Couns 2014;96: 287–94.
Pa˚l Gulbrandsen* Professor, Institute of Clinical Medicine, University of Oslo, and Akershus University Hospital, Sykehusveien 25, 1478 Lørenskog, Norway *Tel.: +47 6796 8718 E-mail addresses: [email protected], [email protected]
