Resource utilization in medicine is becoming an increasingly critical issue (as also noted by the number of discussions we’ve had on it here at CanadiEM), and this acknowledgement is important. However, once we’ve accepted the harms (to the patient and system) with excessive over-utilization, we can begin to look at ways to address and optimize physician behaviour. There are many ways to approach the subject, and one that is often cited is Shared Decision Making (SDM). Here we seek to delve into what exactly SDM entails, how to incorporate it into our practice and how it may influence patient care.
At it’s core, shared decision making is best utilized when there is no strong evidence or recommendations in regards to a particular clinical problem. It involves both the patient and physician to share information, best available evidence and to participate in an shared decision making process that encompasses patient preferences, allowing them to arrive at an informed conclusion regarding their care1.
Most Emergency Physicians are familiar with the concept of SDM, but evidence demonstrates that physicians infrequently utilize it in their practice, and when they do so – it is not often done well2.
Studies have examined barriers (or perceived barriers) to the utilization of SDM in medicine, and physicians have identified a multitude of factors why they do not feel shared decision making has a role in their practice. Most commonly, physicians have cited3:
- Many patient’s prefer that a physician decides
- When offered a choice, patient’s will be more aggressive with their care
- It is too complicated for patient’s to know how to choose
These attitudes and opinions of physicians is further highlighted by patients – who have reported that physicians typically engage in discussions more heavily weighted towards the “benefits” of a particular investigation or therapy4. Despite physicians well meaning intentions to focus on patient care, these perceptions have frequently been demonstrated to be inaccurate, as we will get in to shortly. But another question remains – what do patient’s want?
Literature on this subject certainly does not reflect the most robust scientific data, but numerous patient survey’s have demonstrated that patient’s have a desire to be included in decision making regarding their patient care5. Being involved in these decision making processes results in higher patient satisfaction and greater involvement in their healthcare decisions.
A majority of the evidence looking at shared decision making revolves around general practice medicine, however, a systematic review on SDM in the ED6, demonstrated an positive effect on patient satisfaction, knowledge and involvement in care. They also demonstrated that SDM resulted in decreased healthcare utilization, without any demonstration of harm or lack of feasibility. Examining a number of RCT’s done on chest pain patients presenting to the ED; patient’s were randomized to usual care versus shared decision making – and it was found that SDM patients had fewer negative thoracic imaging tests (9% vs 20%), fewer returns to the ED within 7 days (4% vs 11%), with no difference in length of stay, or adverse cardiac events7.
A Cochrane review on 86 RCT’s on shared decision making demonstrated that it results in increased knowledge gain by patients, more confidence in their healthcare decisions and more involvement in their care – and that informed patients opt for more conservative treatment options2.
Despite an mounting plethora of evidence in favour of SDM, it is still not routine practice for many emergency physicians, and while there is no clear evidence for why, I suspect it is because of a lack of familiarity or comfort in utilizing shared decision making.
It is important to acknowledge that shared decision making should not be utilized in all patients. In those who require a test (i.e.: have a thunderclap headache and associated syncope), testing should be appropriately performed. Similarly, in a patient who a test is not indicated (i.e.:LP and CT head for a routine migraine), imaging should not be offered. SDM is best utilized in those patient’s where there is a lack of evidence to guide decision making, or where evidence is poor. it is a method to help alleviate concerns associated with poor physician risk tolerance, fear of missing an low probability diagnosis or to aid with comfort around diagnostic uncertainly.
There are no clear guidelines or recommendations on how to perform shared decision making. Some literature discusses how to engage patient’s in SDM from a family medicine standpoint, but this is not useful in the ED. Shared decision making, however, can be practically done in the Emergency Department, and incorporated into one’s practice, but a few steps are required. For the purpose of this discussion, we will use a case example.
Suppose you have an 22 year old female who presented with RLQ pain, and suspecting appendicitis you order an ultrasound. Her pelvic exam is normal, there are no high risk features for pelvic pathology and her blood work is normal. Her ultrasound cannot visualize the appendix, but there are no accessory findings of appendicitis. This is a case we see regularly, and ultimately the physician has a few options:
- Perform an CT scan to further investigate the cause of her pain
- Watchful waiting: allow the patient to be discharged home with careful return instructions.
- Have surgery to come and assess the patient to make a decision
Based on practice patterns, ED physicians likely would opt for one the above strategies, but this case affords an excellent opportunity for shared decision making and incorporating patient preferences.
An practical, and useful approach to shared decision making in this type of scenario involves applying the following principles:
With your patient, take a moment to summarize their presentation, what we know currently and any suspected working diagnoses.
Inform your patient that we are at a fork in the road, and there is a decision to be made. There is no strong evidence or guidelines to tell us what to do, and so it is important to make that decision together, incorporating their preferences into their care.
Inform the patient of their potential options (i.e.: in the above scenario), and what each would mean, the risks/potential benefits of each, and how to incorporate the decision into the patient’s care. They should also be made aware that traveling down one path does not preclude any of the other options in the future (i.e.: opting for watchful waiting does not mean they cannot obtain an CT later if they become worse).
Try to illicit if the patient at this point has a strong preference one way or another, or if they have any questions.
Allow the patient to weight their options, perhaps discuss with family members (see another patient, finish some charting).
With the patient, arrive at a decision for their subsequent care.
Some patient’s will suggest that they would want to know what you, as the physician would do. At these times, I tell the patient that the decision in this instance comes down to risk tolerance. Metaphorically, this could be akin to speeding on the highway, the decision to speed or not speed (being aware of risk) is an individual preference, as a manifestation of risk tolerance. I suggest that some people need to have an answer (acknowledging that the CT may not provide this, and may just result in harm), while others can appreciate the logic behind not performing an CT.
Patient’s may wonder why you are asking for their input, and I reiterate that as there is no evidence to guide the decision, any decision made should incorporate their preferences and beliefs, as having only just met them, I do not know what they would opt for in a given scenario.
Documentation with shared decision making is important, not only because it justifies and explains the rationale for why a particular management option was decided upon. It also helps to guide any subsequent physician who may see the patient on a return visit. For example, in the above scenario – if SDM was utilized, and they decided for watchful waiting, upon a return visit for worsening pain, they should likely undergo CT scanning, reflected in your chart – this makes the job much easier for the next physician.
Shared decision making has the potential to significantly argument an influence one’s practice to help minimize the inappropriate utilization of resources, as patient’s using SDM tend to pursue less imaging, and can improve patient satisfaction, and ultimately improved patient care.
Ultimately, shared decision making has many demonstrable benefits, in particular related to decreasing resource utilization and engaging patients in their own healthcare decisions – with no evident harm noted. Patients note increased satisfaction, and tend to opt for less aggressive investigations/treatments. It is an feasible and easy to implement strategy to help augment one’s practice further.