into the teaching of evidence-based practice Tammy Hoffmann 1,2 , - PowerPoint PPT Presentation

Integrating the teaching of shared decision making into the teaching of evidence-based practice Tammy Hoffmann 1,2 , Chris Del Mar 1 , Victor Montori 3 1 Centre for Research in Evidence-Based Practice, Bond University, Australia , 2 SHRS, University of Queensland, Australia, 3 Mayo Clinic, USA

Workshop objectives 1. To raise awareness of the link between shared decision making and EBP and why shared decision making skills should be explicitly taught, and how they can be logically incorporated into EBP teaching 2. To overview strategies and tools for teaching and assessing shared decision making core skills Theme group tomorrow → Integrating the teaching of shared decision making into the teaching of EBP: why, how and what else do we need to know?

Main topics • What does SDM have to do with EBP? • What are some of the skills needed for SDM? • Strategies and tools for facilitating SDM • Some ideas for how to teach and assess these skills • Others?

What does SDM have to do with EBP?

One way of conceptualising the link… from Hoffmann, T., Bennett, S., & Del Mar, C. (2013). Evidence-based Practice across the Health Professions . (2 nd ed)

Another way: Evidence-to-Practice Pipeline Unsound Research Aware Accepted Applicable Able Acted on Agreed Adhered to Sound (3) Research Systems (bottomline +/- ref) Synopses (user summary of research) Systematic Reviews & CATs (search; appraise; synthesis) Studies (primary research: sound & unsound) Glasziou, P., & Haynes, B. (2005). The paths from research to improved outcomes. Evidence-Based Medicine, 10: 4-7.

A benefit of shared decision making…

Shared decision Decision aids making

Conditions with decision aids evaluated in RCTs… Stacey D, Bennett C, Barry M, Col N, Eden K, Lyddiatt A, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2012;

“ A good level of SDM occurs about 10% of the time” SR of 33 studies mean OPTION (Observing Patient Involvement in Decision Making, 0-100) score = 23 Godolphin, W. Shared decision making. Healthcare Quarterly; 2009:12, e186-90. Couët N, et al. Assessments of the extent to which health-care providers involve patients in decision making: a systematic review of studies using the OPTION instrument. Health Expectations, 2013;14.

Barriers to SDM… & training • Lack of time • “We already do SDM” • Not sure what it really is • Not clear what it is meant to achieve • “It doesn’t make any difference to outcomes” • “Most of my patients don’t want to be that involved” Solutions: Patient-mediated interventions e.g. decision support tools or training in questions to ask Health professional training in SDM Legare, F, et al. Barriers and facilitators to implementing shared decision making in clinical practice: Update of a systematic review of health professionals’ perceptions. Pat Educ Couns, 2008; 73:526-35. Towle, A., & Godolphin, W. Putting informed and shared decision making into practice. Health Expectations, 2006; 9:321-2.

Is it typically taught to student clinicians and clinicians?

The teaching of SDM skills… Patient SDM Evidence-based communication skills practice skills skills

Shared decision making: A skill that needs to be taught

When should SDM be taught?

Why teach SDM to undergraduates? • Time when health professionals acquire their professional identity • Time when interview and consultation ‘scripts’ and habits are developed • ‘Hidden’ curriculum – trained to believe it is important to have “the answer” • Lack of role models who practice SDM

Why offer SDM training as CPD? • Most likely not taught when undergraduate • Lack of training is a major barrier to SDM occurring Légaré F, Bekker H, Desroches S, Drolet R, Politi MC, Stacey D, et al. How can continuing professional development better promote shared decision-making? Perspectives from an international collaboration. Implement Sci 2011;6:68. Légaré F, Politi MC, Drolet R, Desroches S, Stacey D, Bekker H. Training health professionals in shared decision- making: An international environmental scan. Patient Educ Couns 2012;88:159 – 69.

Who should be taught? • Skills that are needed by all clinicians Systematic review of facilitators and barriers to the • implementation of shared decision making (Légaré et al 2008): ~ 90% of all study participants were physicians

What should be taught?

What are some of the steps & skills needed? Determining Determining patient’s Developing a patient’s preferences for partnership preferences for his/her role in with the information (amount & decision patient format) making Presenting Discussing Eliciting and likelihood of options , responding to benefits and patient’s ideas, along with the harm/s, concerns, benefit/s and individualising expectations harm/s of each where possible Helping patient Agreeing upon Checking reflect on options an action plan understanding; & impact of & arranging supporting alternative negotiating a follow-up/ decisions , decision or review as considering values agreeing to defer needed and lifestyle

Core skills? • Current debate about ‘core’ skills • Agreement about 2 broad areas of competencies: – Relational skills – Risk communication skills Légaré. F., Moumjid-Ferdjaoui, N., Drolet, R., Stacey, D., Härter, M. Core competencies for shared decision making training programs: insights from an international, interdisciplinary working group. J Contin Educ Health Prof. In press.

One model: Choice, option, decision talk Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared decision making: a model for clinical practice. J Gen Int Med 2012;27:1361 – 7.

5 Questions • What will happen if I wait and watch? • What are my test or treatment options? • What are the benefits and harms of these options? • How do the benefits and harms weigh up for me? • Do I have enough information to make a choice?

Key steps to communicating evidence General strategies and skills for effectively communicating with patients + 1. Understand the patient’s experiences and expectations 2. Build partnerships 3. Discuss the evidence, including a balanced discussion about uncertainties 4. Present recommendations 5. Check for understanding and agreement Epstein, R., et al. (2004). Communicating evidence for participatory decision making. JAMA , 291:2359-66.

Teaching ‘communicating numbers’ skill • Tips and tricks • What to teach, resources to use, etc HOFFMANN, T., & Tooth, L. (2013). Talking with patients about evidence. In T. Hoffmann, S. Bennett, & C. Del Mar (eds). Evidence-based practice across the health professions (2 nd ed). Sydney: Elsevier. pp. 328-352.

Decision support tools • Even when decision aids are available and appropriate, their use is not straightforward and training health professionals in their use may be needed. • Various types of decision support tools available • Finding them… • Appraising them… Tiedje K, et al. “They leave at least believing they had a part in the discussion”: Understanding decision aid use and patient-clinician decision-making through qualitative research. Patient Educ Couns. 2013;93:86 – 94.

Decision support tools Registry of decision aids • http://decisionaid.ohri.ca/resources.html

What do we know about how to teach SDM to students?

Studies to date of teaching students… • Hoffmann, Del Mar, et al. (under review) Brief training of student clinicians in shared decision making: a randomised controlled trial. • Han, et al. Development and evaluation of a risk communication curriculum for medical students, Pat Educ Couns, 2013. • Morrow, et al. Shared decision making: Skill acquisition for Year III Medical Students. Fam Med, 2011; 43:721- 5.

Background to Hoffmann et al RCT • Already full curricula (in EBP course & elsewhere) • But important topic! • Brief intervention needed • Have always taught this topic/skills, but was it effective?

For Discussion …