Hi Kev, Ben, Glyn and everyone
Perhaps I see the Share Decision Making (SDM) from a different perspective.
Hospitals doctors often share their decisions or explain them to other doctors, nurses and students on ward rounds, so in this sense, ‘SDM’ happens even when patients do not share actively in the process.
When in clinics we usually make decisions in a similar setting as primary care physicians.
However, after explaining our proposed decision to the patient, we also share our decision by proposing it to the referring doctor in a letter, often dictating it in the patient’s presence and then sending a copy to the patient.
In the Oxford Handbook of Clinical Diagnosis I teach students and young doctors how to prepare such explanations by linking each action in their records to a diagnosis and
linking each diagnosis to its ‘evidence’. I heard the term ‘evidence’ used in this way during my training a long time before the term ‘evidence-based medicine / health care’ was coined and had to be prepared to provide such ‘particular’ patient
evidence for any decision on ward rounds (as well as ‘general’ research evidence from the literature when appropriate).
In many situations, the best option is obvious to everyone, including the patient (e.g. applying pressure or a touriquet for bleeding or giving antibiotics for suspected
meningitis). Also many patients cannot or do not wish to participate in decisions (often because they are too ill or distressed) and ask the doctor to suggest what he or she would wish for in their place.
However, the best option is often not immediately obvious and it is also very common for patients to ask to participate in decisions.
In these circumstances an approach of the type used by Glyn Elwyn of setting out options in a grid helps to make transparent the process of electing the most suitable option for the patient after a diagnosis has been made.
This approach also helps to explain to students, nurses and other doctors the factors taken into account to arrive at a decision even when a patient does not participate.
I couple information of the type provided by Glyn Elwyn's option grids with the following question about a hypothetical RCT: “If we had a large number of completely identical
patients and we randomised them into groups and treated each group with one of the options available, which option do we guess would provide most frequently the best overall result from the patient’s point of view?”
Published RCTs in a similar situation help answer such hypothetical questions of course.
However, this highlights the tentative nature of such decisions. ‘Decision Analysis’ provides a way of setting up a mathematical model of such a hypothetical RCT.
However, when I put such hypothetical questions to a group of students, doctors, nurses, relatives and patients on ward rounds, it is surprising how frequently such guesses agree.
In many cases we cannot convince ourselves that any of the interventions will make much difference (i.e. the estimated NNT is very high).
After doing all this I find it helpful to record a particular patient’s ‘evidence-based’ explanation of what was agreed by everyone who shared in the decision.
This is done by (1) Ensuring that all the options chosen have been listed clearly.
(2) For each option, linking it to the related diagnosis. (3) For each diagnosis linking it to the related patient ‘evidence’ (those parts of the patient’s history, signs and test results) used to arrive at the diagnosis and to arrive at
the decision options linked to that diagnosis. This can be done in the day to day notes, letters, discharge summaries (and sometimes a printed, up to the minute ‘Past Medical History’ for the patient).
I agree with Ben that it may be impossible to know if the method used or the choice made in any particular situation was the best one because for one thing we cannot turn
back the clock to try again (although in some slowly evolving situations we can try different approaches).
This issue was discussed in a recent post on 'patient centred care'.
Also, many patients may be risk averse (or the opposite) and may not make a choice where the expected frequency of predicted outcome equals the actual frequency of outcome in the long run for all their decisions in different settings.
At least, involving the patient reduces the chances of a decision harmful to the patient being made for someone else’s benefit such as a budget holder who wishes
to reduce costs or a doctor who stands to avoid censure for missing a target or loss of fees for an omitted item of service.
There have been many scandals recently in the UK which appear to have been caused by such a ‘target culture’ that diverts attention away from the patient's needs.
I agree with Kev that such pressures are well known to influence decisions. Transparency in decision making may not be able to eliminate such conflicts of interest but at least they can be minimised.
Huw
Dr Huw Llewelyn MD FRCP
General Physician and Endocrinologist
Hon Fellow
Aberystwyth University
Mobile +447968528154
Dear Huw,
To its credit, EBHC has drawn attention to the need to give information to patients (such as using easily understood summary stats) and the need to incorporate patient's values and preferences in decisions. For too long, however, it has concentrated on
the content of communication and overlooked the process. Check the EBHC textbooks, you will find lots on decision aids, including even the the rarely feasible decision tree with lots of branches where we are supposed to give the precise probabilities for each
choice, something we rarely have. You will find very little on the consultation skills that you need to do some vital things, like for example, (1) establishing whether the patient wants to participate in decisions (2) assessing the verbal and numerical skills
of the patient (3) packaging the information into palatable chunks (4) checking understanding and lots more.
From the standpoint of the GP world where a lot of research and development has gone into consultations, I drew attention to this deficit at a Conference on teaching EBHC at Hanze University, Groningen, Netherlands in 2006 and I still believe that we in
the EBHC world should draw on the existing body of knowledge. I am not sure we need a separate heading of SDM. For an example of what I mean, you could look at
·
Applying The Evidence: Acceptability at http://www.angliangp.org.uk/evidence_based_GP.htmKev Hopayian
Dear Glyn, Tammy and all
I fully support the incorporation of SDM into EBM. SDM involves incorporating using the patient’s own ‘evidence’ to predict which option will probably benefit that patient best. This ‘evidence’ is based on the patient’s past personal experience and is combined
with the collective, carefully documented experience of researchers studying groups of patients (which is what is usually regarded as the ‘evidence’ of evidence-based medicine). Any evidence based on past experience (of the patient or researcher) can be termed
‘general’ evidence, and evidence based on the patient’s symptoms, signs and test results in a particular situation can be termed ‘particular’ evidence. These terms are based on ‘particular’ and ‘general’ propositions in logic.
The individual patient’s current symptoms, signs and test results is an essential part of the total ‘evidence’ that is used to arrive at diagnoses and to choose the course of action that will probably provide the greatest benefit. So in order to be transparent
about ALL the evidence that is used to share a medical decision with a patient, it is important to specify which symptoms, signs and test results were used to arrive at each diagnosis in that ‘particular’ patient and the resulting choice of treatment (see
pages 9, 10 and 11 of Chapter 1 of the Oxford Handbook of Clinical Diagnosis
http://fds.oup.com/www.oup.com/pdf/13/9780199232963_chapter1.pdf).
I have practiced and taught this approach to sharing and agreeing diagnoses and decisions and documenting them at the bedside and in clinics throughout my career. This approach and how to link each diagnosis and decision to the evidence used to make them is
also explained in Chapter 1 of the Oxford Handbook of Clinical Diagnosis (see for example pages 12, 13, 16 and 17). I would therefore like to suggest the Oxford Handbook of Clinical Diagnosis as another resource that also promotes ‘Shared Decision Making’
at the point of care.
Huw
Dr Huw Llewelyn MD FRCP
General Physician and Endocrinologist
Hon Fellow
Aberystwyth University
Mobile +447968528154
________________________________________
From: Evidence based health (EBH) [[log in to unmask]] on behalf of Tammy Hoffmann [[log in to unmask]]
Sent: 30 June 2013 23:06
To: [log in to unmask]
Subject: Re: Shared Decision Making Conference Lima
Dear all
Thanks for your post Glyn. We couldn’t agree more about the need for closer alignment of EBP and SDM.
One of the ways to promote the uptake of SDM is for teaching about SDM (and the skills needed to do this) to occur as part of EBP teaching (either in workshops or in more formal courses; at both the undergraduate level and for clinicians)
A small group of us (myself, Chris Del Mar, and Victor Montori) are planning to hold some discussions and a workshop about this issue at the Evidence-Based Health Care International Joint Conference in Sicily in October.
As part of this, we would like to gather together any existing resources which people are already using to teach clinicians (and student clinicians) how to talk with patients about evidence and how to facilitate shared decision making.
We're aware of some resources, but suspect there may be many more and often ones that are only used locally. We'd be grateful if you could email these to me. After the conference, we'll happily share the compiled list of resources (and the resources themselves
where possible) and a summary of the issues discussed with the list.
Many thanks
Tammy
Associate Professor Tammy Hoffmann
Centre for Research in Evidence-Based Practice
Faculty of Health Sciences and Medicine
Bond University Gold Coast, Queensland, Australia
Tel: +61 7 5595 5522
www.crebp.net.au
http://works.bepress.com/tammy_hoffmann/
-----Original Message-----
From: Evidence based health (EBH) [mailto:EVIDENCE-[log in to unmask]] On Behalf Of Glyn Elwyn
Sent: Thursday, 27 June 2013 9:54 PM
To: [log in to unmask]
Subject: Shared Decision Making Conference Lima
Dear Colleagues
Just joined this listserv - you may have already seen this - so apologies for repeats.
A Mayo-led team (Montori/LeBlanc) organised the 7th conference in Lima (terrific by the way), where Gordon Gyuatt gave an excellent keynote.
Keynote: EBM needs SDM needs EBM with Dr. Gordon Guyatt
http://isdm2013.org/video-archive/
Others from the EBHC community gave workshops. Interesting to reflect in 2013 how I got into this SDM area from a kick-off in Oxford-based week-long events many years ago, where Greenhalgh, Milne, Sackett, and many others were strong on the need for evidence
etc.
High time even more bridges were built between EBHC (sample based data) and the need to respect individual, yet informed, preferences (personal level decision making).
There was evidence of culture dissonance for sure - the word 'recommendation' - weak or strong - was under debate in one workshop where GRADE was under the spotlight. Yet the mood was one of a genuine attempt to integrate these population / individual stances
somehow. Looking forward to those conversations.
Glyn
Professor Glyn Elwyn
BA MB BCh MSc FRCGP PhD
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The Dartmouth Center for Health Care Delivery Science | USA The Dartmouth Institute for Health Policy and Clinical Practice | USA Scientific Institute for Quality of Healthcare | University Nijmegen Medical Centre | Netherlands.
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