Practice Perfect 646
Who Makes the Decisions – You, the Patient, or Both?

When deciding on a course of treatment for your patients, do you tend toward the authoritarian side, telling patients what they need? Or are you more interactive, discussing treatment options and working with patients to decide on the best course of action? This latter idea is termed “shared decision making” (SDM) and has been the subject of increasing amounts of research as medicine aims to empower patients and improve outcomes. Is SDM the best way to approach a patient-centered health-care system and how can providers best leverage this to help our patients? 

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Does the Evidence Support SDM? Kinda-Sorta

In January 2015, Shay and Lafata1 published a systematic review on shared decision-making and patient outcomes. They found 39 studies that measured SDM and at least one patient outcome. Overall, only 43% of studies found a significant positive relationship between SDM and outcomes but varied somewhat by measurement type with the patient-reported success of 52%, observer-rated 21%, and clinician-reported 0% success.  Unfortunately, most of the studies were observational in nature and reported survey types of self-descriptions.

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Slightly more recently Kashaf, et al performed a systematic review and meta-analysis on outcomes in patients with Type 2 diabetes, finding 16 studies to analyze. Similar to Shay and Lafata, these researchers noted an association between SDM and patient perceived improved decision quality, knowledge quality, and risk perception. They found no association between SDM and “glycemic control, patient satisfaction, quality of life, medication adherence or trust in physician”.2

Involving patients in the decision process at least makes them feel that they’ve achieved a better outcome. But I’ve found no evidence that their medical outcomes actually did improve.
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Although both studies state higher quality studies are necessary, it is interesting to note the larger patient-reported successful outcomes and improved perceptions, presumably due to their active involvement in the decision-making process. We may state loosely that involving patients in the decision process at least made them feel that they had improved. These aren’t strict medical outcomes, but when we’re talking about including patients in the process, their views become important.

Appreciating the Ratio to Best Help Patients

For me, this is a somewhat more complex issue than simply telling patients what to do versus having them tell us what to do. I think of this as a ratio of involvement and there are several factors that work in concert to determine that ratio of decision-making between patient and physician. Consider these factors:

  1. Age – Certain older patients come from a time where physicians were heavily authoritarian. These patients may be more comfortable with an authoritarian doctor.  
  2. Generation – Younger generations such as millennials don’t hold the same regard for authority that older generations do and often prefer to take a much more proactive approach to their medical issues. This may require a higher level of shared decision-making.  
  3. Diagnosis and Complexity– Some diagnoses are highly complex and may be difficult for patients to gather the complete understanding necessary to make truly educated decisions. Genetics, for example, has become increasingly important to cancer treatment, and few people besides oncologists will have a deep enough understanding of the process to make a well informed treatment decision.  
  4. Ability to Adhere – Certain patient situations may affect the ability to adhere to a physician’s instructions. For example, a homeless patient may have difficulty adhering to a healthy diet prescribed for his diabetes, thus affecting his outcomes. This type of situation will require a much greater level of physician-patient interaction to effect positive outcomes.  
  5. Education – Level of education varies between patients and will affect both the understanding of a particular medical problem and, in some, their sense of empowerment to make decisions. This may require a greater amount of physician-led interaction. 
Involving our patients probably doesn’t improve specific medical outcomes, but it does appear to improve patient perceptions of the quality of decisions and risk understanding, both are helpful to maintain strong, empowered relationships with our patients

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In the end, caregivers must recommend treatments based on the best available evidence, our own experience, and our patients’ needs and desires. We can use the research data to understand that involving our patients probably doesn’t improve specific medical outcomes, but it does appear to improve patient perceptions of the quality of decisions and risk understanding, both of which are helpful to maintain strong, empowered relationships with our patients.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
jarrod@podiatry.com
References
  1. Shay LA, Lafata JE. Where is the evidence? A systematic review of shared decision making and patient outcomes. Med Decis Making. 2015 Jan;35(1):114-131.
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  2. Saheb Kashaf M, McGill ET, Berger ZD. Shared decision-making and outcomes in type 2 diabetes: A systematic review and meta-analysis. Patient Educ Couns. 2017 Dec;100(12): 2159-2171.
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