Yesterday, while reading the New York Times I stumbled upon an article by Pauline Chen addressing issues with doctor patient communication. In the article, Dr Chen describes a highly educated, articulate patient who was unwilling to speak up and discuss care related issues with her doctor. The reasons given for not wanting to speak up included not wanting to anger the physician and not giving the perception of questioning judgement. I immediately began to reflect on one of my recent blog posts on patient compliance and outcomes. During the course of researching that particular blog topic, I found much published that suggested that patient-doctor partnerships in care were key to positive outcomes. Certainly, if a well educated, academic patient like the one described in the New York Times is reluctant to discuss care related issues with her provider, what about the rest of the world’s patients? Maybe this is the largest barrier to achieving more positive outcomes and better compliance.
First and foremost, providing high quality care means doing what is right for our patients. We all learn in medical school and residency the “gold standard” diagnostic test and the first line therapy for many disorders. However, there are often several options that are within the scope of standard of care. The option that we may choose for a patient may have a significant impact on therapy success (even when treatment options have data to support equivalent outcomes). Moreover, how we go about choosing which option to utilize in a particular patient has a lot to do with how successful the therapy may be. Involving patients in this type of choice and providing the patient with decision tool aids is critical to this process.
A recent review by Dr Michael Barry published in the J Ambulatory Care Management in 2012, explored this very issue. The concept of Shared Decision Making is defined in the same journal in 2012 by Dr Angela Coulter as “a patient working together with clinicians to select appropriate treatments or management options”. Shared decision making is an obvious approach when patients are facing major procedural decisions such as whether or not to have an ICD implanted. In order to use this approach there must be more than one acceptable option with acceptable outcomes. However, these options often have different types of side effects and patterns of therapeutic effects. In addition shared decision making can be used when trying to decide about whether or not to use a particular screening test that may have far reaching implications (such as mammograms in younger women–often yielding false positive results and necessitating follow up breast biopsies). As clinicians we must present the outcomes data for a particular test or intervention and help our patients decide (together, as a team) what is best for them and their overall situation.
With these concepts in mind tools to aid in decision making have been designed specifically for certain diagnoses. Decision making tools can be utilized to aid patients in making difficult treatment or testing decisions. The International Patient Decision Aids Standards (IPDAS) provides quality standards for decision aids. These decision making tools are designed for particular disease states and are created to provide information about options to patients. They are NOT designed to promote one option over another nor are they designed to replace a consultation with a physician. According to the IPDAS, “they are specifically designed to prepare patients to make informed, value-based decisions with their practitioner.” These tools are created to facilitate the shared decision making process. They do NOT replace the communication process with the physician–they are created to enhance it.
So, it is obvious that shared decision making requires communication. We must find a way to remove barriers to communication. As physicians, we must work to avoid giving our patients the perception that they are “questioning judgement” or “bothering the busy doctor” when they ask questions during a routine office visit. In fact, at every office visit, we should introduce a time for questions. In my EP practice, before the patient leaves the room, I try to ask if there are any issues they would like to discuss and try to have them assess their progress. By involving them in discussions at every visit, I hope that I am able to open the door for future patient-initiated discussion. We know from numerous studies that patient engagement is key to successful outcomes. Now we must make sure that our patients, regardless of education or socioeconomic status feel free to ask questions, challenge treatment plan decisions and discuss options for care. We must strive to remove barriers to communication and facilitate shared decision making. When patients are not afraid to speak up in the doctor’s office, care is exponentially improved.