Objectives At the end of this workshop you will: Understand the key components of shared decision making (SDM) Build skills and learn about tools to support shared decision making with patients Practice methods of training residents in shared decision making techniques
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Shared Decision Making Training: Tools and Techniques Library/SGIM/Meetings... · Objectives At the end of this workshop you will: Understand the key components of shared decision
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Objectives
At the end of this workshop you will:
Understand the key components of shared decision making (SDM)
Build skills and learn about tools to support shared decision making with patients
Practice methods of training residents in shared decision making techniques
Faculty Introductions
Charles Brackett, MD, MPH – Dartmouth
Hitchcock Medical Center Kathleen Fairfield, MD, MPH, DrPH – Maine
Medical Center Karen Sepucha, PhD – Massachusetts General
Hospital Leigh Simmons, MD – Massachusetts General
Hospital Jon Tilburt, MD – Mayo Clinic
Shared decision making
Interactive process between patient (and family) and clinician(s): Engage patient in decision making Accurate information about options and
outcomes Tailors treatments to patient’s goals and
concerns To be successful in implementation:
Receptive culture for clinicians, staff, administration
Engaged, prepared patients Infrastructure and resources Clinicians skilled in conducting SDM
Goal of shared decision making
The right treatment, for the right patient, at the
right time
R. Wexler, FIMDM
A word on taxonomy
Effective care Strong evidence base supports care Benefit to harm ratio high All with need should receive it
Preference sensitive care Evidence supports more than one approach Treatment/testing options involve significant
trade-offs Personal values, preferences and life
circumstances should drive decisions Many of our treatment decisions do fall into
this category
SDM Sweet Spot
How many times have you heard these from your residents?
“Before I graduate, he will get that colonoscopy!”
“I can’t believe she’s not taking the statin; I thought we were on the same page.”
“I just order a PSA on all my men over 50. Makes it easier.” Or:
“I don’t even talk with my patients about the PSA. We don’t have to do it anymore, right?”
Not just communication skills…
Distinct set of skills and steps required to conduct SDM effectively
(Though there is much overlap with evidence based medicine and communication skills training)
Six Steps to Shared Decision Making
1. Invite patient to participate 2. Present options 3. Provide information on benefits
and risks 4. Elicit patient preferences 5. Facilitate deliberation and decision
making 6. Assist with implementation
Invite Options Benefits and Risks Patient Preferences Deliberate and Decide Implementation
Credits: R. Wexler, FIMDM, and K. Clay, Center for Shared Decision Making, Dartmouth-Hitchcock Medical Center
Decision Aids Can Help
Tools designed to help people participate in decision making about health care options.
Provide information on the options
Help patients clarify and communicate the personal value they associate with different features of the options
(The International Patient Decision Aid Standards Collaboration )
Patient decision aids do not advise people to choose one option over another
Not meant to replace practitioner consultation
Prepare patients to make informed, values-based decisions with their practitioner
(The International Patient Decision Aid Standards Collaboration )
Decision Aids Can Help
Decision Aids: Tools to Facilitate SDM
Longer, outside of visit In-depth information, used outside of
consultation Web-based Video Print
In-Consultation Tools (Web, Option Grids) Short, FAQ with answers Used during visit Clinicians find it easier to conduct SDM with
tool (Elwyn 2012)
Evidence base: Decision Aids (DAs)
2011 Cochrane Systematic Review contains 86 RCTs and finds that decision aids Increase decision quality:
14% increase in knowledge 74% increase in realistic expectations 25% increase in value-choice concordance
Engage patients in decision making
39% less passive Address over- and under- use of certain tests and treatments
20% reduction in elective surgery 15% reduction in PSA use 27% reduction in HRT use
Stacey et al. Cochrane Database of Systematic Reviews, 2011
Healthwise Decision Points
Values Clarification
Option Grids
SDM and Milestones
SDM skills support the core competencies of interpersonal and communications skills, professionalism, systems-based practice, and practice-based learning
SDM skills frequently referenced in the 22 ACGME/ABIM proposed milestones mapped to the core competencies; highlights include:
2. Comprehensive management plan development
16. Professional and respectful interactions with patients and team members
18. Unique patient characteristics and needs
20. Effective communication with patients and caregivers
Creating a culture for SDM to happen
Best methods for training residents in SDM not yet known
A hospital culture that is receptive to shared decision making is best (residents learn a lot by “osmosis”)
Shared Decision Making @ Mayo Clinic:
A Culture Change Approach
Jon Tilburt, MD
SGIM Workshop Integrating Shared Decision Making
Into Graduate Medical Education Denver, CO
April 27, 2013
Organizational Context
• Fortune 100 corporation, 57,000+ • Large non-profit group practice • Multi-state, multi-site • Small medical school; big residencies • Everything is centered around the practice • Old fashioned medicine, 21st century
challenges • “The Needs of the Patient Come First” • Franciscan Values: dignity & service
The Example of St. Francis
• Sharing “good news” means embodying a compelling message
Context: Human Capitol
• Huge workforce devoted to team • “Lone Rangers” typically leave town • EBM scholarship • Ethics scholarship • Risk prediction research • Professionalism/Communication • Institutional push to show practice
• You can’t give what you don’t have • Offer an appealing alternative • Plan with values not base on “value” • Exploit positive community norms • “Magic School Bus” research *Stephen R. Covey, Seven Habits of Highly Effective People
Living our values
How to Do it: Offer an appealing alternative
• Are underlying values of SDM there? • “Be the change” (Ghandi) • Rested, Flexible, Humble, Open-