Issue: January 2016
January 16, 2016
6 min read

Shared decision making can lead to better, individualized care

Issue: January 2016
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Today’s patients are more educated than ever before, and many expect decisions about their care to be made in a collaborative manner with their doctor.

“Shared decision making (SDM) ensures that patients and their eye doctors are making choices that are best for each individual patient,” Lori L. Grover, OD, PhD, FAAO, dean of the Pennsylvania College of Optometry at Salus University, told Primary Care Optometry News. “If all treatment options are effectively presented with the best available information, patients are fully informed for making optimum decisions about their health and health care. That is an incredibly powerful way to improve the patient experience, patient and provider satisfaction, and overall health outcomes.

“SDM is the process of effectively involving patients, and doctors making treatment decisions that are informed by the best available evidence, the potential pros and cons of treatment options, and incorporating patient preferences,” she added

The Society for Medical Decision Making (SMDM) describes medical decision science as proposing standards for ideal decision making. This science involves studying how physicians and patients make decisions and identifying both barriers to and facilitators of effective decision making, the SMDM says on its website. Those in this field strive to develop tools that can guide physicians, patients and health care policymakers to make good decisions in practice.

Lori L. Grover, OD, PhD, FAAO, said doctors have an ethical responsibility to facilitate patient involvement in seeking to improve outcomes.

Image: Grover LL

In a 2006 study aimed at understanding how patients wish to improve medical care from BMC Health Services Research, researchers found that getting more information from the physician and taking part in decisions were most important to patients.

“Understanding the patient’s narrative, providing all information and joint decision-making are increasingly recognized as essential elements of care giving ... being well informed by their doctors and allowed to take an active part in decisions is a major preference for a great many patients,” the researchers wrote.

Paradigm shift

Patients wanting to know more about their health care, according to private practitioner Martin Carroll, OD, increases the opportunity to communicate and educate.

“Before, the doctor told the patient what they needed, and that was the end of the conversation. But now there is more discourse between the patient, the doctor and the rest of staff. There may be occasional difficulty, but we’ve embraced it,” Carroll told PCON.

“Over the past few decades, there has been a paradigm shift in physician-patient communication,” Peter A. Ubel, MD, a behavioral scientist at Duke University, said in an interview. “In the 1950s and 1960s, physicians frequently told patients very little about their health care circumstances. Most physicians in the U.S. now recognize the importance of informing patients about the pros and cons of their treatment alternatives.

Peter A. Ubel

“Unfortunately, physicians are not always adept at explaining complicated medical decisions in a way that patients comprehend, and many forget to check whether their patients understand their health care choices,” Ubel continued. “In addition, many physicians fail to understand their patients’ core values well enough to make individualized treatment recommendations. Physicians still have a long way to go to learn how to partner with patients in making important medical decisions.”

Patient experience, relationship

According to Carroll, often the experience that people have is more important than the medical care that they receive. He explained that if the patient has a good experience with you, it is more likely that he or she will do what you prescribe and follow the treatment protocol.

‘The most important thing is building an emphatic relationship with the patient,” Richard Wexler, MD, chief clinical integration officer at Healthwise, said in an interview. “If patients feel cared about and cared for, that creates a deep sense of trust. Providers have to walk in the shoes of their patients; they have to know what their life is like and then they can better understand what the patient is interested in and what’s realistic to do in the context of their life circumstances.”


Wexler offered the analogy of eating at a new restaurant.

“You might not always remember what you ate, but you’ll remember how you felt and how you were treated,” he said. “If you had a great or bad experience, you are more likely to tell others about it.”

Harue J. Marsden, OD, MS, FAAO, a professor at Southern California College of Optometry at Marshall B. Ketchum University, believes having well-educated patients makes her life easier and builds patient trust.

“When patients trust you they are more inclined to return as a patient vs. ‘shopping around,’” she said.

Six steps to shared decision making

When asked what he would recommend to a doctor who wants to begin implementing SDM, Wexler thinks the first step can be the most impactful: inviting the patient to participate. The invitation is necessary, he said, as most patients will be reluctant to speak up. Inviting the patient is the first step of a six-step framework he helped develop to incorporate SDM methods.

Step two involves presenting options to the patient often with the use of decision aids, he said. Step three encompasses providing information on the benefits and risks of the options. Step four consists of helping the patient evaluate the options based on his or her goals and concerns. Step five is facilitating the decision making process. Finally, step six involves helping the patient implement the decision. These steps do not need to be followed sequentially, he said, but at the end of a SDM conversation they can act as a checklist for providers to keep in mind.

Richard Wexler

Other tools for SDM

Patient decision aids are integral to patient education and understanding complex vision issues. New technology has made it easy to send them to patients, often in advance of a planned visit, according to Wexler. They can be online and viewed on cell phones, and the information can be personalized.

Capturing how patients interact with the decision aids is also important. Patient statements about their decision or goals can be documented and put back into the electronic health record, which allows for a SDM conversation to occur more easily, according to Wexler.

Carroll’s staff uses layman’s terms to go over complex vision issues with patients, so even children can understand. They use models, handouts and audiovisual aids to offer explanations and descriptions of various vision problems.

Martin Carroll

Grover has developed scripts and keywords that make complex vision issues less scientific and easier to understand for patients. She recommends basic tools such as charts and other visual decision aids

Marsden encourages getting to know your patient. “It would be so easy if health care were like appliance repair,” she explained, “where you could drop off what is broken and then pick it up when fixed. We sometimes forget that the eyes are part of someone, and because of the integration with health and well-being it is important to know the type of patient that you are working with.”

“By giving patients decision aids written in plain, accessible language and then personalizing the message during a shared decision making discussion, doctors impart their expertise to a patient,” Wexler said. “The other side is recognizing that the patient is the expert on who they are, what is important to them and what their life is like. If this conversation occurs, patients are able to better act on improving their health.”

Marsden sees electronic medical records as a hindrance to care, with the doctor’s focus too often on the computer screen.

Harue J. Marsden

“Historical perspective is overlooked if it existed prior to the EMR,” she said. “I went to a cardiology appointment with my father, and the physician spoke toward the computer the entire visit. When I asked him about my father’s status following his five-way heart bypass, which was 10 years prior, the doctor was surprised at this history, even though my father’s paper records were right next to the computer. I’ve also experienced this when dealing with practitioners where the previous records are scanned and linked to the EMR, but we often don’t go through the previously scanned records for a comprehensive review.”

SDM aligns with health care reform objectives by seeking to improve patient outcomes, reduce overtreatment and reduce overall cost, according to Grover. Doctors have an ethical responsibility to facilitate patient involvement as well. With SDM, doctors no longer assume what the patient wants; there is active engagement.

However, solid economic data on the practice is lacking, she said.

“We are hoping that, over time, long-term data collection will show how this practice is helping to mitigate overtreatment and reduce health care costs,” Grover said. – by Abigail Sutton

Disclosures: No product or services were mentioned in the article that would require financial disclosure.