The new experts in healthcare: Patients

  | June 9, 2017

In an age of high deductibles and “Dr. Google," the dynamic between physician and patient is shifting. Is it time for shared decision-making to enter the mainstream?

The concept — empowering patients to determine the course of their treatments, in consultation with a trusted provider — has been around since the 1980s. Researchers laud its potential to lower costs while improving patient satisfaction. Yet the process has still not been widely adopted in clinical practice. For many physicians, shared decision-making feels at odds with evidence-based protocols — and requires an investment of time and training.

Troy Long, M.D., an internal medicine doctor and physician leader at Colorado Permanente Medical Group (CPMG), went through the transition himself — and now advocates for shared decision-making as an executive consultant on population healthcare for PMG Healthcare Solutions, a physician-led consulting firm created by CPMG.

athenaInsight spoke with Long about candid conversations, best practices, and his own shift from “paternalistic doctor" to partner.

When did you first learn about the concept of shared decision-making?

In my residency days, in our patient-interaction classes, shared decision-making was introduced briefly: “You should be asking questions, finding barriers, and trying to determine what's going on with your patients, so that they can make decisions that are appropriate for themselves." And yet, early in my career, I was still a paternalistic doctor. I felt I knew what was best for my patients rather than recognizing that they knew best what was right for them. I was not well attuned to adopting the shared decision-making approach.

What changed?

I started to recognize that my practice wasn't going the way I wanted it to. My patients were not engaging in their health as much as needed, and I was not helping them engage in the medical system or their own health. There are always those pivotal moments when you try something new and it works, and you switch the way that you're going to do things forever. This was one of them: I had been discussing mammograms with a patient, using evidence-based guidelines to convince her to get it done.

When I accepted her desire to decline mammograms, the visit progressed much more positively. I explained that I would still ask her if she would get a mammogram at future visits to be sure not to miss an opportunity. She said, “As long as I can still decline then I am comfortable with you asking." That began a very trusting, collaborative relationship. Several years later, she got her testing done after a close friend had a breast cancer diagnosis.

What do you do if a patient makes a decision likely to lead to a poor outcome?

I involve patients in whatever I'm typing in their health record. I'll turn the computer to them — and they usually watch over my shoulder, anyway — and say, “I just want to document what we have here, so make sure that I use the words that you and I have used. We know that you're having some rectal bleeding, and that the gold standard of treatment at this point would be a colonoscopy, but you have declined that. And we've talked about the risk. Does that sound right to you?" Many times, writing language that reflects our discussion changes their decision on the spot.

How do you fit these conversations into a 10-minute patient visit?

It takes an extra three to five minutes the first time. But the next time it only takes 30 seconds, and the time after that you say, “Are you ready to quit smoking?" and it's a 10-second discussion. The more time you invest in the beginning of the relationship, the better outcomes you will have in the end.

How should physicians start incorporating shared decision-making into their practice?

The place to learn how to engage patients in shared decision-making is in less-than-life-threatening situations. Smoking, for example. An elderly gentleman came in for a hospital discharge follow-up for a COPD (chronic obstructive pulmonary disease) exacerbation. He was still smoking. As we discussed his tobacco use in relation to his recent hospital stay, the importance of quitting or even cutting back, I asked what things were the most important in his life. And he said, “smoking."

His daughter asked him “What about us?" and he frankly stated, “Smoking is number one. I really like it and am not going to quit." I told him, “If things change, I am here help you quit in the future if you want to, but for now we will work to control your current symptoms." We had a very long and productive relationship, but he never did quit.

Does every patient want to participate in shared decision-making?

The patients 60 and older, many times, will say in the exam room, “You're the doctor, I'm going to follow what you have to say." Younger patients are more likely to challenge: “Why should I do this? What's the evidence behind it? If I find other evidence that I believe, can you look at it with me, and help me understand it more?" Younger patients are more than open to shared decision-making — they demand it. And females more than males, by the way.

What, in addition to transparency and mutual respect, does shared decision-making require to change patient behavior?

Patience. I had a patient, a gentleman in the 400-plus pound range. We talked about his weight at his initial visit and he said, “I feel perfectly fine. I'm comfortable with my weight, and my life is just great." I said, “Well, I'd like to continue talking to you about it as we see each other." At each appointment we got a little farther and, at one point, I gave him a handout I had compiled of successful weight-loss stories of other patients.

About a year and a half later, he came back and said, “You don't recognize me, do you?" I said, “I didn't have a chance to review the chart before I went in the room. I know your name, but I just can't place you." He said, “Well, I lost 150 pounds, and I feel a heck of a bunch better now. You gave me the time to do what I needed to do for myself."

Why does shared decision-making matter so much?

Shared decision-making is, in my mind, the pinnacle of the doctor-patient relationship. You've gotten to a point that patients trust you, and you trust them on a higher level than what the typical doctor patient relationship allows. The doctor and patient may not agree, but you're able to continue the relationship due to the mutual respect you share.

Gale Pryor is associate editor of athenaInsight.

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I believe shared decision making is one of the cornerstones of patient-centered care...and this post aligns well with the recent post by Dr. Hanekom about the patient/physician relationship. https://insight.athenahealth.com/there-can-be-no-secrets-between-us In that post, Dr. Hanekom stresses the importance of understanding a patient's financial circumstances and ability to bear out-of-pocket costs when discussing treatment options. The financial discussion should be an explicit part of shared decision making. This is also why price/cost transparency by providers and health plans is critical.
Name: 
Steve Raetzman
Email: 
Steve@raetzman.com
Shared decision making and Informed consent are key elements of patient engagement. Performing and documenting these will be important in value evaluations in the future.
Name: 
Monty Duke
Email: 
lmduke@lghealth.org
Great article and something that every doctor should be doing and every pharmaceutical rep should be helping doctors to implement in their practices.
Name: 
Mike Allison
Email: 
mike@mikeallisoncoaching.com
Great article and I agree with what Steve Raetzman has to say. High deductible insurance has certainly changed the game, I think for the better in some cases. I am far more careful in my prescribing habits with ALL of my patients. I have a question: what about antibiotics, I have MANY patients who swear that the only way they will get better is with an antibiotic. I patiently explain why antibiotics will not cure a viral infection, talk about risks of over prescribing and risk of side effects however they still insist that they know their bodies best. What role does shared decision making play here?
Name: 
Mylene Kedrock
Email: 
Mkedrock@ffpcs.com

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The new experts in healthcare: Patients