Promoting Shared Decision
Making
Jack Fowler
Informed Medical Decisions
Foundation
Shared decision making means
• 1. Patients are told about all reasonable
options
• 2. Patients are told about pros and cons of
options
• 3. Patients share goals, concerns and
preferences with providers
4 Reasons Not to Increase Efforts to Do
Shared Decision Making
• 1. We already do it
• 2. Patients don’t want it
• 3. Patients can’t understand
• 4. Doctors should make decisions
We already do it?
National Survey of Medical Decisions
• Cancer screening tests:
– Colorectal Cancer
– Breast Cancer (mammography)
– Prostate Cancer (PSA testing)
• Prescription medication decisions:
– Hypertension
– High Cholesterol
– Depression
• Surgical interventions:
– Knee/hip replacement
– Cataracts
– Lower back pain
Mean Proportion of Knowledge
Items Answered Correctly
0%
50%
100%
Medication Initiation:
High blood pressure
69%
High cholesterol
49%
34%
Depression
Cancer screening:
Colon cancer
43%
Breast cancer (women)
Prostate cancer (men)
37%
17%
Elective surgery:
Knee/hip replacement
32%
Cararact
Lower back pain
49%
25%
Discussion of Pros and Cons“some” OR “A lot”
0%
50%
100%
Medication Initiation:
82%
High blood pressure
31%
83%
High cholesterol
34%
79%
Depression
39%
Screened for Cancer:
Colon cancer
Breast cancer (women)
Prostate cancer (men)
73%
14%
75%
13%
69%
16%
Underwent surgery:
90%
Knee/hip replacement
Cararact
49%
76%
33%
72%
Lower back pain
62%
% Discussed Pros
% Discussd Cons
Did HCP Offer an Opinion and
Ask for Patient’s Own Opinion?
0%
Medication Initiation:
50%
100%
84%
High blood pressure
41%
85%
High cholesterol
45%
78%
74%
Depression
Screened for Cancer:
Colon cancer
Breast cancer (women)
84%
34%
80%
38%
80%
Prostate cancer (men)
46%
Underwent surgery:
Knee/hip replacement
85%
77%
78%
Cararact
61%
82%
Lower back pain
76%
HCP offered opinion
Asked pt. opinion
PATIENTS DON’T WANT IT?
Testing our First 30Minute BPH
Program
How would you rate the
amount of information?
One Universal Truth
• Every time we ask, people (particularly
physicians) underestimate how much patients
value getting information about their medical
conditions and being involved in decisions.
At Dartmouth-Hitchcock
• Patients routinely see decision aids for at least
11 different decisions
• They are surveyed after they see them
Who Should Make Decisions?
Dartmouth patient data collected between July 2005 and July 2009
Would You Recommend DA for Others
Dartmouth patient data collected between July 2005 and July 2009
Patients can’t understand?
Findings with Respect to Literacy
• Compared understanding of risk reduction for
samples of college students and senior citizens
recruited from community centers
• Both groups were stratified by score on a
numeracy test
Percent of Respondents
Who Understood Risk
Reduction by Numeracy
Level and Quality of Data
Presentation
Percent of Respondents
Who Understood Risk
Reduction by Numeracy
Level and Quality of Data
Presentation
Doctors should make decisions?
Top Three Goals and Concerns for Breast
Cancer/Herniated Disc Decisions
Condition: Goal
Patient
Provider
p
Surgery:
Keep your breast?
7%
71%
P<0.01
Chemotherapy:
Live as long as possible?
59%
96%
P=0.01
Reconstruction:
Look natural without
clothes
33%
80%
P=0.05
Reconstruction:
Avoid using prosthesis
33%
0%
P<0.01
We are not doing it now
Patients do want it
• But many perceive their doctors do not
welcome questions and patient participation
in decision making
Patients can absorb complex
information
• However, it has to be presented well
Decisions should not be delegated to
physicians
• Because most medical decisions involve trade
offs and quality of life issues
• Providers will not know what patients care
about unless they ask
• At the moment, they do not routinely ask
• SO THAT IS WHY WE ALL NEED TO WORK TO
PROMOTE THE IDEA THAT PATIENTS
ROUTINELY
• SHOULD BE INFORMED ABOUT THEIR
OPTIONS AND THEIR PROS AND CONS
• HAVE A VOICE IN MEDICAL DECISIONS
THANK YOU.