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Objectives
At the end of this workshop you will:
Understand the key components of shared decision making (SDM)
Build skills and learn about tools to support shared decision making with patients
Practice methods of training residents in shared decision making techniques
Faculty Introductions
Charles Brackett, MD, MPH – Dartmouth
Hitchcock Medical Center Kathleen Fairfield, MD, MPH, DrPH – Maine
Medical Center Karen Sepucha, PhD – Massachusetts General
Hospital Leigh Simmons, MD – Massachusetts General
Hospital Jon Tilburt, MD – Mayo Clinic
Shared decision making
Interactive process between patient (and family) and clinician(s): Engage patient in decision making Accurate information about options and
outcomes Tailors treatments to patient’s goals and
concerns To be successful in implementation:
Receptive culture for clinicians, staff, administration
Engaged, prepared patients Infrastructure and resources Clinicians skilled in conducting SDM
Goal of shared decision making
The right treatment, for the right patient, at the
right time
R. Wexler, FIMDM
A word on taxonomy
Effective care Strong evidence base supports care Benefit to harm ratio high All with need should receive it
Preference sensitive care Evidence supports more than one approach Treatment/testing options involve significant
trade-offs Personal values, preferences and life
circumstances should drive decisions Many of our treatment decisions do fall into
this category
SDM Sweet Spot
How many times have you heard these from your residents?
“Before I graduate, he will get that colonoscopy!”
“I can’t believe she’s not taking the statin; I thought we were on the same page.”
“I just order a PSA on all my men over 50. Makes it easier.” Or:
“I don’t even talk with my patients about the PSA. We don’t have to do it anymore, right?”
Not just communication skills…
Distinct set of skills and steps required to conduct SDM effectively
(Though there is much overlap with evidence based medicine and communication skills training)
Six Steps to Shared Decision Making
1. Invite patient to participate 2. Present options 3. Provide information on benefits
and risks 4. Elicit patient preferences 5. Facilitate deliberation and decision
making 6. Assist with implementation
Invite Options Benefits and Risks Patient Preferences Deliberate and Decide Implementation
Credits: R. Wexler, FIMDM, and K. Clay, Center for Shared Decision Making, Dartmouth-Hitchcock Medical Center
Decision Aids Can Help
Tools designed to help people participate in decision making about health care options.
Provide information on the options
Help patients clarify and communicate the personal value they associate with different features of the options
(The International Patient Decision Aid Standards Collaboration )
Patient decision aids do not advise people to choose one option over another
Not meant to replace practitioner consultation
Prepare patients to make informed, values-based decisions with their practitioner
(The International Patient Decision Aid Standards Collaboration )
Decision Aids Can Help
Decision Aids: Tools to Facilitate SDM
Longer, outside of visit In-depth information, used outside of
consultation Web-based Video Print
In-Consultation Tools (Web, Option Grids) Short, FAQ with answers Used during visit Clinicians find it easier to conduct SDM with
tool (Elwyn 2012)
Evidence base: Decision Aids (DAs)
2011 Cochrane Systematic Review contains 86 RCTs and finds that decision aids Increase decision quality:
14% increase in knowledge 74% increase in realistic expectations 25% increase in value-choice concordance
Engage patients in decision making
39% less passive Address over- and under- use of certain tests and treatments
20% reduction in elective surgery 15% reduction in PSA use 27% reduction in HRT use
Stacey et al. Cochrane Database of Systematic Reviews, 2011
Healthwise Decision Points
Values Clarification
Option Grids
SDM and Milestones
SDM skills support the core competencies of interpersonal and communications skills, professionalism, systems-based practice, and practice-based learning
SDM skills frequently referenced in the 22 ACGME/ABIM proposed milestones mapped to the core competencies; highlights include:
2. Comprehensive management plan development
16. Professional and respectful interactions with patients and team members
18. Unique patient characteristics and needs
20. Effective communication with patients and caregivers
Creating a culture for SDM to happen
Best methods for training residents in SDM not yet known
A hospital culture that is receptive to shared decision making is best (residents learn a lot by “osmosis”)
Shared Decision Making @ Mayo Clinic:
A Culture Change Approach
Jon Tilburt, MD
SGIM Workshop Integrating Shared Decision Making
Into Graduate Medical Education Denver, CO
April 27, 2013
Organizational Context
• Fortune 100 corporation, 57,000+ • Large non-profit group practice • Multi-state, multi-site • Small medical school; big residencies • Everything is centered around the practice • Old fashioned medicine, 21st century
challenges • “The Needs of the Patient Come First” • Franciscan Values: dignity & service
The Example of St. Francis
• Sharing “good news” means embodying a compelling message
Context: Human Capitol
• Huge workforce devoted to team • “Lone Rangers” typically leave town • EBM scholarship • Ethics scholarship • Risk prediction research • Professionalism/Communication • Institutional push to show practice
relevance • Respected Sage/Guru/Prophet
Sage/Guru/Prophet
• @vmontori • http://minimallydisruptivemedicine.or
g/tag/victor-montori/
Aphorisms: How to instill Change
• Work outward from your “spheres of influence”*
• You can’t give what you don’t have • Offer an appealing alternative • Plan with values not base on “value” • Exploit positive community norms • “Magic School Bus” research *Stephen R. Covey, Seven Habits of Highly Effective People
Living our values
How to Do it: Offer an appealing alternative
• Are underlying values of SDM there? • “Be the change” (Ghandi) • Rested, Flexible, Humble, Open-
minded, Forgiving • “Constructively countercultural” • Example: physical proximity • Example: user-centered design
Appealing Decision Aids
• In-visit DAs • http://shareddecisions.mayoclinic.org
/decision-aids-for-diabetes/Designer on the team
• Flattened hierarchy • Iterative process • URI
Where are we going?
• Expanding spheres of influence (No short cuts to leadership) • Expanding circles • Coping w/bandwidth & burnout • CME integration • Thinking big
A Closer Look
3 Models of Resident Training Maine Medical –
Standardized patients
Dartmouth – Trigger Tapes, Video Decision Aids
Mass General – “Choice Reports”, SDM in Chronic Conditions
Using Standardized Patients to Teach Residents Skills in Risk
Communication and Shared Decision Making:
The Maine Medical Center Experience
Objective: To develop curricular
materials, teach, and evaluate residents skills in shared decision making in
common clinical scenarios
Development
Developed 2 cases • CRC screening: decision to screen or not, and
use of colonoscopy vs FIT • Mammography for breast cancer screening for
women in their 40s Trained Standardized Patients (SP)
• Concepts of SDM • Issues we wanted them to bring up
CRC: cost, prep, time off from work, risk Mammogram: false positives, fear of not doing it
• Goals of the exercise • Giving feedback using the OPTIONS tool
Logistics Residents received 5 minute introduction
• Update on screening guidelines, using pictograms to explain absolute risk
First case: • Residents receive “door instructions” before entering
room with SP • 20 minute SP event with 1st patient • SP completes Options tool and debriefs 5 min
Group debrief with faculty and SDM Talk focusing on the behaviors associated with SDM
Second case: • Same steps as first
Final Debrief Total time about 3 hrs
The Dartmouth Experience
Charles Brackett, MD, MPH
SDM in Primary Care • Distribution of IMDF Decision Aids (7 of past 8 years)
– By “prescription”- ordered through EMR – Previsit delivery of cancer screening DAs
• PSA mailed to 50 year olds • Pre-visit questionnaire
– Diabetes – Orthopedic referrals
• Clinician Training/Marketing – Lunch talks – Emails – Exam room posters/references – SDM weblink in EMR (DA summary tools, risk calculators)
Residency Training
• Half day workshop for IM residents (11/09) – Mix of didactic, trigger videos, and role play
• Impact Evaluated by analysis of audiotape of standardized patient encounters in clinic at 1 mo and 6 mo after workshop (vs. control- RCT, n=41)
• Faculty: 3 lunch time talks
• Current: 1 hour with director of CSDM during intern clinic orientation; role modeling
Didactic Content
• Background/Why is SDM important? • Communication Skills
– Risk communication – Eliciting Values and Preferences – Recognizing and resolving decisional conflict – Checking for understanding
• Decision Aids
Lessons Learned
• Discomfort with uncertainty • When is SDM appropriate? • Initiating SDM: equipose • Importance of faculty buy-in/training/role
modeling • One page AF DA was popular
Resident training in SDM at Mass General
Best methods for training and for assessment are not yet known
Chronic condition management relatively under-studied in SDM literature
Opportunity to study and apply SDM to chronic condition management
Curriculum for residents
Focus groups (elicit issues and challenges with chronic condition management)
2 hour training session Case study (baseline)
Training and introduction of methods and tools (Choice Reports)
Assessment (research study component)
Tools for SDM conversations
Choice Reports Present options on a
grid Designed to facilitate
conversation, not for stand-alone use
Pros/Cons detailed Option of “doing
nothing” presented Choice Reports
developed for 4 target conditions: Hyperlipidemia Hypertension Diabetes Depression
Deep Dives
Breakout groups – choose 2 15 minutes at each Table 1: Maine Medical - OSCE Table 2: Dartmouth – Trigger Tapes,
Video Decision Aids Table 3: Mass General – “Choice
Reports”, SDM in Chronic Conditions
Reflections
Highlights? Questions? Concerns Is there one new thing you can try
at your home institution?
