Decision support tools are designed to ease shared decision-making and patient involvement on health care decisions. When patients actively participate in decision-making and understand what is required of them, they are more likely to follow through. To establish an efficient shared decision making process, physicians must consider patients values, preferences and circumstances. In this month’s episode of CMPA Practically Speaking, our experts discuss the importance of patient’s decision aids to overcome communication challenges and build a strong patient-physician relationship.
Announcer: You’re listening to CMPA: Practically Speaking.
Dr. Yolanda Madarnas: Hi Steven.
Dr. Steven Bellemare: Hi Yolanda, how are you?
Yolanda: I’m well, thanks. I wonder. Sometimes it doesn’t hurt to restate the obvious.
Steven: Well I agree. You know, and actually, it would lend itself very well for this particular podcast.
Yolanda: Yeah. So we know that communication with patients can be challenging.
Steven: Yeah, obvious, right? That’s absolutely true. Probably the hardest thing we’ll ever do. Even the best of us can actually find it difficult to build a strong relationship in a very short period of time.
Yolanda: Yeah, especially in the setting of where we have changing patient demographics, physician demographics, a mix of diverse culture, language barriers.
Steven: More engaged and more informed patients or maybe even misinformed.
Yolanda: Absolutely.
Steven: And scarcity of physician time.
Yolanda: Yeah. So this—I think this helps explain why communication-related issues are a number one factor that we see in many of our medico-legal files.
Steven: And in fact, Yolanda, if you read the literature, it’s all over the place.
Yolanda: Yeah.
Steven: Patient-physician communication issues are a big problem. Some of the challenges that, you know, that we note in our files have to do with establishing rapport with patients, communicating clearly, honestly and directly, and checking for patient understanding of their diagnosis and their treatment options, for instance.
Yolanda: Yeah. But let’s not despair because there really are ways that we can improve on our personal communication skills and our communication styles…
Steven: Oh, for sure.
Yolanda: And techniques and tools. And coming to today’s topic, is the use of decision aids, so deliberately approaching communication with our patients with a shared decision-making approach that might include the use of a decision support tool, is one concrete way that we can address these important problems.
Steven: And this is exactly what we’re trying to do with these podcasts, right, is provide some concrete examples of some little changes we could try in our practice, to try to make it overall better.
Yolanda: Yeah.
Steven: So by decision support tool, we’re actually talking about patient decision aids and you’ve used the term before, something that you use with patients to help move the discussion forward, to promote patient understanding. And that’s not to be confused with clinical decision support tools that may be part of an electronic medical record system and that are designed to actually help with identifying relevant differential diagnoses.
Yolanda: So these patient decision aids are used for the more complex decisions that we sometimes have to face with our patients, where we need more detailed information and more careful consideration of a variety of complex options.
Steven: Yeah. Complex decisions often involve multiple options that people value differently. Sometimes the scientific evidence about options is limited and how we value each one can play a major role in how we decide to proceed.
Yolanda: Absolutely. So, you know, the best choice depends on the importance a patient places on the benefits, the harms, and the scientific uncertainty. So the goal of using a patient decision aid is to improve the quality of that decision-making process and ultimately, the quality of the decisions.
Steven: And you know, Yolanda, the quality of the decision hinges on the extent to which the patient feels they chose care that’s congruent with their values.
Yolanda: And those values will help our patients better understand and better be able to make trade-offs between benefits and risks of one option, one treatment, one test, over another.
Steven: And that’s entirely their choice, isn’t it?
Yolanda: Absolutely.
Steven: So, using patient decision aids can be helpful for the physician, too, right? It can help structure discussions and make them fulsome, allowing for the patient inputs to be provided and as such, to create some dialogue.
Yolanda: Absolutely. So with regards to the decision aid concept and tools, we want to offer three take-home messages today.
Steven: As we normally do, right? The first one would be shared decision-making approaches to treatment and screening discussions increase patient engagement and satisfaction.
Yolanda: And I wonder. By extension, could it possibly decrease medico-legal risk?
Steven: Well maybe, right? Improving communication between a patient and their physician certainly couldn’t hurt, but using them will require some investment of time on your part.
Yolanda: Right. And bear in mind as well that the use of these tools may not necessarily lead to an instant decision. We need to manage our expectations of such a tool and our patient’s expectations as well.
So take-home point number two would be using decision aids is one technique we can use to facilitate shared decision-making.
Steven: Right. And take-home number three would be that shared decision-making is the link between person-centred care and informed consent. Isn’t that profound?
Yolanda: Sometimes the simplest is the most challenging to accomplish.
Steven: Yeah.
Yolanda: So, let’s take a case, an example, say, a 55-year-old male, we’ll call him Joe, who comes to see you and says I heard about this blood test for prostate cancer, this PSA, and he wants it done because he’s afraid of prostate cancer. Joe is asymptomatic and he has no family history. So what would you tell him?
Steven: Well, I guess we could just say sure, let’s do it and leave it at that. That would be an option.
Yolanda: Well, doing what a patient wants as the path of least resistance might not exactly be the best way to go about reaching sound decisions, and it could even be viewed as a somewhat paternalistic approach to medicine.
Steven: Right.
Yolanda: And the whole point of this podcast is to talk about how you could engage patients in a shared decision-making process, using a decision aid.
Steven: And you know if you were younger and you responded no, that’s necessary. Well, that would be no better.
Yolanda: Just as paternalistic.
Steven: Right.
Yolanda: In both cases, it’s the lack of dialogue about the why of the medicine, be it a PSA, a mammogram, an MRI, a surgery, a vitamin, w, x, y, z assay that makes the care not person-centred.
Steven: Right. You know, Yolanda, there was a study back in 2019 in the CMAJ and it showed that older patients in rural settings that lived in the province of Quebec, specifically, and are in part of a visible minority group, actually perceived significantly decreased levels of shared decision-making.
Yolanda: Well that’s interesting. I wonder what reasons would explain that.
Steven: I suspect it’s either not being done or it’s being poorly done. What we do know from the literature, is that it seems the barriers include gaps in physician knowledge, either about what clinical situations or patients are appropriate for this approach, or thinking that it’ll take too much time.
Yolanda: So our take-home point—one of our take-home points today was the shared decision-making approaches increase patient engagement and patient satisfaction.
Steven: Right.
Yolanda: However, it doesn’t quite seem to be the norm yet in many areas of clinical practice, like in some worlds, like my own oncology, for example, such tools and decision aids are used quite extensively, but it’s not necessarily the case across all domains of medicine.
Steven: And some might actually think they are engaging in shared decision-making. But you know, we all have blind spots and sometimes taking the opportunity to receive feedback from a colleague or actually from our patients about how well we engage in shared decision-making, it can actually be a good starting point to improve our care.
Yolanda: Well that would really make a fantastic topic for those self-assessments, high value credits, right?
Steven: Right, for CPD. Everyone’s always looking for ways of getting feedback about their practice.
Yolanda: Absolutely.
Steven: So this would be a great topic for sure. You know, working towards being a better communicator can be worth its weight in gold in terms of job satisfaction, too, right? Shared decision-making is just such a way to be a better communicator. It’s a conversation between a physician and a patient, where the physician shared medical information that’s relevant to a health decision. And the patient shares information regarding their values and preferences and together, they arrive at a collaborative decision.
Yolanda: So let’s come back to Joe’s case. If I asked Joe and about his values, he might not really know what I mean. But so it’s how I say it. So it might be better to say I’m curious to understand why you’re asking about this test now, Joe.
Steven: Absolutely. You know, I think you’re right. If you said to people what are your values? They’d look at you like a deer in the headlights probably. So the phrasing and the tone are very important here, right? You don’t want to come across as critical either and you know there are some scripts available as well when you don’t quite know what to say and it doesn’t come naturally. I’m thinking specifically for discussions around opioids, for instance. There are some very nice scripted conversations that you could rehearse or follow that could be of help.
Yolanda: So really, it’s about finding out what our patients want, what they think, what’s going on in their lives right now, what concerns they have so that we’re better equipped to help them.
Steven: Now, Yolanda, shared decision-making takes time, as I said before...
Yolanda: Yeah.
Steven: And that can be a concern for some.
Yolanda: It can, absolutely, but, we can’t stress enough that investing that time is absolutely worth it in the long term. The dividends and the return on that investment are huge in terms of general satisfaction with care on the part of patients and families, and the relationship where it is strengthened. And our article in Perspective, speaks to some of the literature on this topic.
Steven: Right. And I think we’ve mentioned it in another podcast too, where we have to think about how much time we want to invest now with the clinical interaction versus how much time do we want to invest in responding to a college complaint...
Yolanda: Yep.
Steven: Because the patient wasn’t satisfied…
Yolanda: Yeah.
Steven: With the interaction.
Yolanda: Absolutely.
Steven: You know, some patients, though, may not be used to sharing decision-making and we may actually have to socialize them to that concept so to speak.
Yolanda: Yeah.
Steven: The previous or their other doctors may in fact, not have engaged in shared decision-making and so they can be very confused.
Yolanda: Yeah. So Joe would say well, you’re the doctor. You tell me.
Steven: And actually, Yolanda, that’s exactly the kind of situation where using the decision tools might be helpful to a patient like Joe.
Yolanda: Yeah, to help us elicit their values and foster a better understanding, both on our part and theirs, of what the needs are in this situation.
Steven: Right. And if patients push back a bit, that’s actually okay in a clinical conversation. It’s an opportunity to learn.
Yolanda: Absolutely. So, there are various models in the literature that promote the shared decision-making concept. But fundamentally, it’s about two things: communicating risk and clarifying patient values.
Steven: Essentially, shared decision-making can be framed as being based on choice, option and decisions.
Yolanda: Yes. We first introduce a choice and then we describe a series of options.
Steven: And that’s where integrating the use of a patient decision support tool can actually be very helpful.
Yolanda: So that you can finally help your patients explore their preferences and approach to making decisions.
Steven: So with Joe, in step one, you would introduce the choices of PSA screening or not screening, or other options if they’re relevant.
Yolanda: And then in step two, you could describe the options and the data around each option. So for example, what proportion of men in his age group has a negative test? Or what proportion of men in his age group have a cancer detected earlier than had they not had the screening test done?
Steven: And that type of data is exactly what’s in the patient decision aid, right? And then having reviewed that that may explain the fact that the test may not be the panacea that Joe was expecting it to be.
So then in step three, you would discuss Joe’s preferences and values as they relate to his informed decision. For example, which risk would matter most to him? Does he prefer to test and risk a false positive and all the potential treatments and investigations that would ensue? Or does he prefer to do nothing with the understanding that most likely the test would not change anything anyway for him.
Yolanda: And that is uncertainty.
Steven: Right.
Yolanda: There are benefits and risks on both sides of that process. But instead of me telling Joe, nah, you don’t need the test. Or sure, let’s do it and leave it at that, you’ve given Joe the opportunity to understand and to decide for himself what fits his needs bests.
Steven: So before we go, though, it’s important to say that not all decision aids are created equal.
Yolanda: That’s true. So there are standards used to evaluate decision aids and there’s an entity called the International Patient Decision Aids Standards (IPDAS) Collaboration, quite the mouthful. And in general, there are a number of things to look at to determine if we have a good decision aid. They include, in a first instance, we like to see that the decision aid has included both positive and negative consequences of a clinical decision with the outcome probabilities, as you described.
Steven: Right.
Yolanda: Secondly, the decision aid describes options so that patients can imagine the outcomes in each of those settings using their personal values when approaching the decision.
And finally, the decision aid links to the evidence that was used to create them and describe the synthetic process or the process that was used to come up with this tool.
Steven: And that’s actually critically important because…
Yolanda: Absolutely.
Steven: That’s important for you, right? To critically assess the quality of the patient decision aid and the literature upon which it’s based. Just like we learned to do with medical literature….
Yolanda: Correct. We don’t want to propose something that was fished out of a hat in a fly-by-night operation. We want something that’s founded on evidence.
Steven: Right. And so often, the professional societies might be the ones who actually are putting out these decision aids, which actually is probably also a good hint about their quality.
Yolanda: Absolutely. And it’s important to remember not only, you know, certain speciality societies or entities like the one I referred to, at times our own institutions or facilities might have their own decision aids in certain settings. So if relevant, it might be important to be aware of what’s being used in your community or in your practice setting.
Steven: Right and again, that goes back to being aware of the standard of care and applying it to your practice, one of the concepts that we bring up frequently in podcast.
Yolanda: You’re right. And we interweave this all the time into our discussions.
Steven: Yeah. You can’t talk to a reasonably—a respectable CMPA physician without talking about standard of care or documentation, right?
Yolanda: So hopefully it’s not too confusing for you, but Steven, I’m still curious, do you think decision aids might actually help decrease our medical legal risk as physicians?
Steven: Well, it’s not the use of the aid per se, it’s the benefit that it brings in terms of your relationship with the patient, I think. The concept of readiness to make a decision, I think is the key to a strong doctor-patient relationship and embarking on a treatment endeavour.
Yolanda: And coming back to that point you mentioned of consent. We very frequently see in our medico-legal files that there are problems with consent and that hinge on either poor patient selection that our experts identify as a problem with the consent process where the patient wasn’t ready to accept the risks or didn’t understand them well. This is a setup for dissatisfaction with the care and very often for medico-legal risk.
Steven: But you know it may be a fallacy to believe that at the end of one discussion, our patients will be able to choose. The patients may very well need to take this home with them, mull it over and think about it more before they can actually decide.
Yolanda: Yeah. It’s a process. It’s not plug-in the data, poof spits out an answer. It is a process that requires time and our acknowledgement of that process, in fact, epitomizes patient-centred care and moves away from paternalism and bases itself on dialogue. In fact, I’ll take that one step further, where consent and person-centred care intersect, is where shared decision-making lives.
Steven: Well that’s profound, Yolanda. I like it. It’s about promoting the patient participating in informed consent, having a say in what happens to them.
Yolanda: And it’s important to remember that we interpret these tools through the lens of our own medical knowledge, balanced with our understanding of our patients values and expectations and above all, that no tool is perfect and as with most things in medicine, it’s important that we not be too rigid as well.
Steven: Right.
Yolanda: So Steven, I think it’s time for a communication tip.
Steven: Well Yolanda, I would suggest that my tip would be leverage patient teach-backs. Use patient teach-backs in your interactions. So first, teach or discuss the decision or the concept, then ask the patient to repeat that information in their own words. So patient teach-back essentially does two things: it promotes information retention because the patient actually has to synthesize that information to be able to reword it, and it also allows you to assess whether or not there are gaps in the patients understanding, if the patient misunderstood or misses a key part of the information, you know about it and you can explain it again.
So how about you, Yolanda, do you have a documentation tip for our listeners?
Yolanda: At the risk of repeating ourselves, document. We cannot stress enough the importance of good documentation. And that’s not a message we haven’t said before at the CMPA, but really, seriously. If you used a decision aid to help your patient’s discussions, document it. And don’t just document that you used it, but keep a copy of the tool on the patient’s file. Send the patient home with a copy of the decision aid so they can process it, digest it and share it with their family, because sometimes the family’s values are important in their decision-making process, so documentation is more than just writing it in the record that you used it, but keep a copy, send it home with them, let them process it.
Steven: And that’s really important because keeping a copy of the version of the tool can actually help you later on to understand why you may have suggested to go one way or another. Remember, these tools change over time. As the data improves, as the science evolves, the stats that those decision aids and then…
Yolanda: Quoted are framed in that time set. It is also helpful not wanting to tempt fate, but in the event we had to defend, well we set the standard of care based on that. We’re not going to compare care delivered in 2001 to care delivered in 2021. And if you used a decision aid that quoted data from X year that will frame what the standard of care was at that time.
Steven: Well said and thank you for coming to my rescue there because I was just at a loss for words.
Well Yolanda, it really is the end of the podcast. I think we’ve gone overtime now. So thank you everyone for listening to Practically Speaking.
Yolanda: Yes, thanks for joining us today. Remember we welcome your comments, your questions and any ideas you might have.
Steven: We do. We do and you can email us at podcasts@cmpa.org.So that’ll be it for today, everyone, thank you very much. And remember, Yolanda, when we change the way we look at things…
Yolanda: The things we look at change.
Steven: Goodbye, everyone.
Yolanda: Goodbye.
Announcer: These learning materials are for general educational purposes only, and are not intended to provide professional medical or legal advice, nor to constitute a “standard of care” for Canadian health care providers.