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Sharing difficult decisions


Last week, Lisa Rosenbaum wrote in a New Yorker blog entry about a topic dear to my heart: shared decision making (SDM). SDM refers to doctors empowering patients to make medical decisions based on their values and preferences when there is more than one reasonable path. Many researchers have found that shared decision making (with the help of decision aids) leads to more informed decisions and may even lower health care costs

As Lisa points out, this approach doesn’t apply to every decision or appeal to every patient. My parents, who grew up in India, feel they haven’t gotten their money’s worth if their doctor cedes too much to their untrained judgment. Some of my co-residents have grown frustrated with repeated institutional reminders to use SDM, arguing that their patients don’t have the education to weigh choices and make informed decisions, and that it’s hard to make time for it in a short visit. I get these concerns. And like Lisa, I worry that codifying SDM in law (like we have done in the US with the Affordable Care Act) may entice doctors to simply go through the motions.

But I think SDM has value beyond its literal practice. I see SDM as a language and as an attitude, one that that has been too rare among physicians. And there is its implicit humility, the doctor’s admission that in areas of clinical uncertainty, her patient’s values and preferences deserve attention.

I’ve tried to take this to heart when talking to my patients. Along with the Informed Medical Decisions Foundation, I’m about to launch a pilot of shared decision making at my primary care clinic. Our medical assistants and physicians will walk our patients through web-based decision aids that grapple, to start, with two medical decisions that have no right answers: prostate cancer screening and the treatment of knee osteoarthritis (the long-term effects of wear and tear on the joint). I don’t expect every patient to come away with one hundred percent certainty about her decision, or for every provider to find the aid useful or even usable in the short time allotted for a visit.

If, at the end of the conversation, a patient prefers me to be the quarterback, I’ll gladly play that role. But I want to have given her the chance to speak up first.

Ishani is a journalist and a second-year resident in internal medicine/primary care at Massachusetts General Hospital.  She blogs at Short  White Coat.  Ishani’s blogs are reprinted on healthydebate.ca with the permission of the author.  Follow Ishani on Twitter @IshaniG.

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2 comments

  1. Kira

    Having spent the last 20years navigating the healthcare system & a long list of doctors, I was thrilled to read this article.

    Of course SDM isn’t going to work for every docfor & every patient, but when it comes to chronic or long term health issues patients are often knowledgable because they’ve had to be. I know how difficult it is to ask questions as a patient with doctors time & availability being so limited. In my case I ask for copies of OR reports, imaging reports etc. if I have questions I’ll write them down in advance so that when I’m at an appointment where the doctor controls the conversation, my questions don’t get lost in the shuffle. If I can’t get a clear answer I’ll go to my family doctor & she helps me sort out the facts, meanings, risks & options.

    I encourage other patients to do the same & if all else fails put your questions & concerns in writing & email or snail mail to the doctor & ask for a written response.

    There are some patients who rely solely on what a doctor tells them or search for answers on the Internet. They don’t recall what treatment they’ve had, what medications they’re taking , etc , but the relationship between a doctor & their patients shouldn’t be based on the lowest common denominator. Especially when a patients can communicate & offer extensive information.

  2. Kathy Kastner

    Ishani, I so appreciate your attitude – about SDM and also about the realities of SDM:

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    As I make my way through end of life education (blogging on http://www.bestendings.com – I think it’s immensely important to understand that decisions – even when shared with a knowledgeble healthcare professional – aren’t necessarily easy.

    It wasn’t until I shared my oncologists statistic with my Ob/GYn brother in law (who put stats into context) that I felt able to make a truly Shared Decision

    Thanks again – and I enjoy reading your blog;)
    Kathy

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