Each “Voices” blog segment will feature a person we believe has a unique and valuable perspective on shared decision making.
Today’s guest is Peter Ubel, MD, author of “Critical Decisions.”
In your own words, what is shared decision making and how does it improve the quality of health care?
Put simply, shared decision making is the gold standard — the sine qua non* — for how medical decisions ought to be made. The right medical choice is rarely a function of medical facts alone. Tough decisions require value judgments, and it is the patient’s values that often determine which choice is best.
An operation cannot be a “success” unless it was the right course of action to take for an individual patient. Treatment cannot “work” unless it was the treatment that best fits that patient’s individual preferences. Quality of care begins with shared decision making.
*Pardon my Latin. After 12 years of Catholic School, I am somehow still failing to use the right ver forms, assuming sine qua non contains a verb. Yikes, my Roman Catholic priest brother is undoubtedly and disappointingly shaking his head right now!
What do you think are the misconceptions of shared decision making?
Misconceptions abound! Let’s start with enlightened providers. I am talking about those health care providers who recognize that patients deserve a seat at the decision-making table. Too often, these providers do not know how to partner with their patients. Instead, many act as if their job is simply to inform patients about their options and let the patients decide, by themselves. That’s a problem in part because many patients don’t want to decide alone. And “alone” is not what shared decision making is about. In addition, physicians often don’t know how to give information in a way easy for patients to understand. In my studies of doctor-patient communication, I have come across hordes of nightmarish examples of well-intentioned physicians overwhelming patients with jargon filled soliloquies. I’ve encountered other examples of doctors refusing to make treatment recommendations, even after patients ask for guidance. And I don’t even want to begin counting how many times I’ve come across physicians who give strong recommendations to their patients without first eliciting the patient’s preferences.
And remember, I’m talking about the enlightened providers! Sadly, many clinicians aren’t so enlightened as to even attempt to share decision-making with their patients. Despite being almost 3 decades into the patient empowerment revolution, there are still many health care providers who see their job as being the deciders. I would say that the Foundation’s work won’t be complete anytime soon!
Do you have a personal story about you or someone you know who could have benefited from shared decision making?
Unfortunately, I do have many such stories, including one very personal one I wrote about at length in my new book, Critical Decisions. It involves my wife facing a serious illness, and facing a series of difficult choices. Our experience revealed to me that even the most informed and assertive patients, ones who have not only the most recent decision aids, but have even perused recent medical literature, are not necessarily up to the task of sharing in important decisions. Other very important barriers still stand in the way.
I am a huge fan of decision aids. I have even helped develop and test a couple of the. And my wife and I made use of a Foundation-developed decision aid when sorting through her treatment alternatives. Moreover, I had conducted research on clinical topics relevant to her situation. But I still discovered that I did not know enough to fully partner in decision-making — decisions were being made (intentional use of passive voice) without our awareness, and doors were being shut without our consent.
If you could change one thing about how we practice medicine today, what would it be?
We need to focus on re-educating clinicians about how to partner with patients — how to elicit patient preferences, and how to anticipate when a decision is a preference-sensitive one. We also need to coach patients, to help them not only learn information relevant to their treatment choices but also to help them find ways of communicating their desires more effectively to their clinicians. Patient empowerment and shared decision making are ultimately implemented one conversation at a time. We need to dig into the social psychology and sociology of the clinician patient encounter, at the same time as develop techniques for helping patients and providers communicate with each other more effectively.
Peter Ubel, MD Peter is a physician and behavioral scientist whose research and writing explores the quirks in human nature that influence our lives — the mixture of rational and irrational forces that affect our health, our happiness and the way our society functions. Peter is the Madge and Dennis T. McLawhorn University Professor of Business, Public Policy and Medicine at Duke University. His research explores controversial issues about the role of values and preferences in health care decision making, from decisions at the bedside to policy decisions. He uses the tools of decision psychology and behavioral economics to explore topics like informed consent, shared decision making and health care cost containment. His books include “Pricing Life: Why it’s time for health care rationing” (MIT Press, 2000) and “Free Market Madness: How economics is at odds with human nature — and why it matters” (Harvard Business Press, 2009). His newest book, “Critical Decisions” (HarperCollins, 2012) explores the challenges of shared decision making between doctors and patients. You can find his blogs and other information at www.peterubel.com.