Shared Decision Making

RECENT POSTS

February 21, 2013 | 2:00 PM | By

Just Say No: Doctors’ Groups Define More Unnecessary Tests, Procedures

CT scan 13 of Clubs_Flickr

One new recommendation: Don’t automatically do a CT scan to check a child’s minor head injury. (13 of Clubs/Flickr)

One of the rallying cries against fee-for-service medicine is this: since doctors are paid to do things to patients (tests, procedures), they are then incentivized to do more things to patients (tests, procedures) than the patient might actually need.

On Thursday, a wide swath of medical groups joined a campaign to list tests and procedures which are commonly done but risk causing patients more harm than benefit.

This “Choosing Wisely” campaign is from a coalition of doctors’ groups — ranging from the American Academy of Pediatrics to the Society of Thoracic Surgeons — in conjunction with Consumer Reports. Last year, the campaign named 45 tests and procedures patients should look at carefully. This year, 17 doctors’ organizations representing 350,000 physicians released 90 additional tests and procedures. Continue reading →

FILED UNDER: Policy, Overtreatment, Shared Decision Making, Unnecessary Care
August 16, 2012 | 11:23 AM | By

In Medicine, Don’t Believe Everything You Know

(Pmccormi: Flickr)

(Pmccormi: Flickr)

By Eve Harris

How do you know your doctor is right? Ideally you and your doctor have a relationship based on trust. That is, you believe she knows the best options to recommend to you. You may think your doctor is right, but — how does your doctor know she’s right? We’d like to think physicians are relying on the latest evidence of medical practice. But not all physicians do that.

I recently joined in a robust, four-day discussion designed to address this issue at the 14th Rocky Mountain Workshop on How to Practice Evidence-Based Health Care. Doctors, policy makers and yes, journalists gathered to explore what many patients might have thought they were already getting: evidence-based health care, also called evidence based medicine.

In evidence based medicine, a hierarchy of evidence guides decisions about patient care. But at the same time, evidence based medicine recognizes that evidence alone is not sufficient. That’s because treatment options come with risks, and different patients will react differently to different risks. It’s not a simple matter of “Drug X” or “Treatment Y” has a five percent higher likelihood of success. If “Treatment Y” involves a risk or side effect a patient finds unacceptable, then this patient’s preference is part of the decision process.

Decision makers must always acknowledge these trade offs.

Continue reading →

FILED UNDER: Policy, You're the Boss, Evidence Based Medicine, Shared Decision Making
July 26, 2012 | 11:26 AM | By

Primary Care Efforts to Involve Patients in Decision Making

(Mercy Health: Flickr)

(Mercy Health: Flickr)

All day, every day, people make medical choices that have repercussions for common yet dangerous conditions like asthma, heart disease and diabetes.  Although chronic disease takes a greater toll [PDF] on people with lower socioeconomic status, chronically ill patients are part of every community. In California and across the country, public health officials and physicians keep searching for the best way to get patients involved in improving their health.

Some patients naturally want to be involved with their care. Other times it’s doctors and nurses who must try to encourage more engagement by their patients. “Whether to exercise or change their diet, take medication,” Dr. David Thom told me recently, “those are the bread and butter decisions that go into primary care.”

Thom, director of research in the UC San Francisco department of Family and Community Medicine, is launching a new study, exploring how patients make decisions when they work with a “health coach.” Often health coaches are trained medical assistants who join the primary care team. “Our belief is that health coaches are going to have a fairly different relationship with patients than providers do,” he says. “Their role in helping the patients make decisions will be clearly different than the providers’ role.” Continue reading →

FILED UNDER: Policy, You're the Boss, Primary Care, Shared Decision Making
July 23, 2012 | 3:47 PM | By

What Do ‘Engaged’ Patients Do?

(Seattle Municipal Archives: Flickr)

(Seattle Municipal Archives: Flickr)

Desiree Basila was 52 when her stage zero breast cancer — also called ductal carcinoma in situ —  was diagnosed. While her cancer was found very early, she was ultimately diagnosed with the disease in both breasts. In addition, it was found in several locations. For Basila, doctors said her only realistic treatment option was double mastectomy — which Basila opposed. “If I die at 75 instead of 95 I think I can live with that,” she told me recently. “I did not really want to have a double mastectomy.”

Basila is strong evidence that individuals react differently to their treatment choices. The new healthcare buzzword is the engaged patient, generally referring to someone who is collaborating with doctors in the decision-making process and, conversely, where a patient’s individual preferences are respected.

Basila became just such an engaged patient. After a cancer diagnosis, people usually have a few weeks to investigate treatment options, options that may be life altering. While Basila had little prior experience with cancer, she had been a science teacher and put her skills to use, digging into the research. She sought a second opinion at UC San Francisco and discovered a new Continue reading →

FILED UNDER: You're the Boss, Breast Cancer, Informed Patients, Shared Decision Making
April 25, 2012 | 2:24 PM | By

Share and Share Alike — Especially in Medical Decisions

By Eve Harris

(Caroline_1: Flickr)

(Caroline_1: Flickr)

Patients often make decisions about their medical treatment while sitting on an exam table in a thin cotton gown. But is this the best way to fully understand your options? Of course, some healthcare decisions are pretty easy. For example, if the treatment being offered is easy to use or has a long history of success with only mild side effects.

But overall, health care decisions are becoming more complex. Your doctor may offer more than one alternative. Picking among those alternatives may have as much to do with medical evidence as your own preferences. The process known as shared decision making empowers patients to collaborate with their doctors in choosing a treatment, as opposed to the doctor pointing a patient toward one choice.

“We have an ethical duty to inform our patients what their options are and get their preferences.”

It all has to do with risks and benefits. In a shared decision process doctors put more effort into explaining trade-offs, and patients must think more deeply about what matters most to them. The relationship of shared decision making to better health is still being studied, but we know that patients who are involved in making their own medical decisions often have less anxiety and recover more quickly. Continue reading →

FILED UNDER: You're the Boss, Shared Decision Making
April 9, 2012 | 2:04 PM | By

Talking About Choices May Encourage Colon Cancer Screening

By: Kamal Menghrajani

Doctor greating patient

Patient-doctor discussions about choices in colon cancer screening may encourage more people to follow through. (Vic Lawrence: Flickr)

Although about 50,000 people in the U.S. died from colorectal cancer (CRC) last year, as many as half of those deaths could have been prevented by routine screening. That’s 25,000 lives that could have been saved using tools that are already widely available.

The problem is getting people to undergo screening can be a bit of a challenge. The “ick” factor of colonoscopies, concerns about paying for them, and other barriers get in the way of adequate screenings. Alternatives do exist, such as the fecal occult blood test (FOBT) – a non-invasive test people can do at home and send into the lab. As reported here in the past, new tools are also being developed that use more advanced science to check for markers of cancer, though these are still gaining traction.

But now doctors are looking at the psychology of how they talk to patients to figure out what might get the most people to get on board with screening.

In a study published today in the Archives of Internal Medicine, researchers from three medical schools, including UCSF, focused on just colonoscopies and FOBT. The study was done in San Francisco through the Community Health Network, and randomized doctors into three study groups: one to recommend only FOBT, one to recommend only colonoscopy, and one to offer patients a choice between the two.

Researchers presumed that recommending just one or the other would send a clear signal and be more effective than giving patients a choice.

They were wrong.

Continue reading →

FILED UNDER: Policy, You're the Boss, Cancer Screening, Colon Cancer, Colonoscopy, Patient-Centered Care, Shared Decision Making
April 5, 2012 | 4:10 PM | By

Please, Don’t Call It Rationing

New Campaign Urges Doctors to Avoid Unnecessary Tests

(Just Us 3: Flickr)

To many patients, it may seem unbelievable that their doctors would recommend something that is completely unnecessary. But by some estimates, that’s exactly what happens a third of the time.

Yesterday a broad coalition of medical specialty groups — including cardiologists and family practitioners — as well as Consumer Reports announced a new campaign, Choosing Wisely. It’s a list of 45 tests and procedures that doctors should do much less often for one simple reason: the items on the list are unlikely to be of benefit to the patient.

The idea immediately raised questions of rationing and that’s exactly where KQED’s Forum started off this morning in discussing the new campaign. UCSF’s Dr. Catherine Lucey, who helped to spearhead the Choosing Wisely campaign, swatted that misconception away.

“It’s not rationing,” she explained. “Rationing of health care is when you deny needed care to patients. … Rationing of health care means patients could get better being given a particular drug of subject to a particular test. This is about tests that in many circumstances do not improve quality of life, do not improve quantity of life and potentially could harm patients.”

Continue reading →

FILED UNDER: Policy, Overtreatment, Shared Decision Making, Unnecessary Care