Objectives At the end of this workshop you will: Understand the key - - PowerPoint PPT Presentation

Objectives

At the end of this workshop you will:

 Understand the key components of

shared decision making (SDM)

 Build skills and learn about tools to

support shared decision making with patients

 Practice methods of training residents in

shared decision making techniques

Faculty Introductions

 Charles Brackett, MD, MPH – Dartmouth

Hitchcock Medical Center

 Kathleen Fairfield, MD, MPH, DrPH – Maine

Medical Center

 Karen Sepucha, PhD – Massachusetts General

Hospital

 Leigh Simmons, MD – Massachusetts General

Hospital

 Jon Tilburt, MD – Mayo Clinic

Shared decision making

 Interactive process between patient (and

family) and clinician(s):

 Engage patient in decision making  Accurate information about options and

• utcomes

 Tailors treatments to patient’s goals and

concerns

 To be successful in implementation:

 Receptive culture for clinicians, staff,

administration

 Engaged, prepared patients  Infrastructure and resources  Clinicians skilled in conducting SDM

Goal of shared decision making

The right treatment, for the right patient, at the right time

• R. Wexler, FIMDM

A word on taxonomy

 Effective care

 Strong evidence base supports care  Benefit to harm ratio high  All with need should receive it

 Preference sensitive care

 Evidence supports more than one approach  Treatment/ testing options involve significant

trade-offs

 Personal values, preferences and life

circumstances should drive decisions

 Many of our treatment decisions do fall into

this category

SDM Sweet Spot

How many times have you heard these from your residents?

 “Before I graduate, he

will get that colonoscopy!”

 “I can’t believe she’s

not taking the statin; I thought we were on the same page.”

 “I just order a PSA on

all my men over 50. Makes it easier.” Or:

 “I don’t even talk with

my patients about the

• PSA. We don’t have to

do it anymore, right?”

Not just communication skills…

 Distinct set of skills and steps

required to conduct SDM effectively

 (Though there is much overlap with

evidence based medicine and communication skills training)

Six Steps to Shared Decision Making

• 1. Invite patient to participate
• 2. Present options
• 3. Provide information on benefits

and risks

• 4. Elicit patient preferences
• 5. Facilitate deliberation and decision

making

• 6. Assist with implementation

Invite Options Benefits and Risks Patient Preferences Deliberate and Decide Implementation

Credits: R. Wexler, FIMDM, and K. Clay, Center for Shared Decision Making, Dartmouth-Hitchcock Medical Center

Decision Aids Can Help

 Tools designed to help

people participate in decision making about health care options.

 Provide information on

the options

 Help patients clarify

and communicate the personal value they associate with different features of the options

(The International Patient Decision Aid Standards Collaboration )

 Patient decision aids do

not advise people to choose one option over another

 Not meant to replace

practitioner consultation

 Prepare patients to make

informed, values-based decisions with their practitioner

(The International Patient Decision Aid Standards Collaboration )

Decision Aids Can Help

Decision Aids: Tools to Facilitate SDM

 Longer, outside of visit

 In-depth information, used outside of

consultation

 Web-based  Video  Print

 In-Consultation Tools (Web, Option Grids)

 Short, FAQ with answers  Used during visit  Clinicians find it easier to conduct SDM with

tool (Elwyn 2012)

Evidence base: Decision Aids (DAs)

2011 Cochrane Systematic Review contains 86 RCTs and finds that decision aids Increase decision quality:

 14% increase in knowledge 74% increase in realistic expectations

 25% increase in value-choice concordance

Engage patients in decision making

 39% less passive

Address over- and under- use of certain tests and treatments

 20% reduction in elective surgery  15% reduction in PSA use  27% reduction in HRT use

Stacey et al. Cochrane Database of Systematic Reviews, 2011

Healthwise Decision Points

Values Clarification

Option Grids

SDM and Milestones

 SDM skills support the core competencies of

interpersonal and com m unications skills, professionalism , system s-based practice, and practice-based learning

 SDM skills frequently referenced in the 22

ACGME/ ABIM proposed milestones mapped to the core competencies; highlights include:

• 2. Comprehensive management plan

development

• 16. Professional and respectful

interactions with patients and team members

• 18. Unique patient characteristics and

needs

• 20. Effective communication with

patients and caregivers

Creating a culture for SDM to happen

 Best methods for

training residents in SDM not yet known

 A hospital culture

that is receptive to shared decision making is best (residents learn a lot by “osmosis”)

Shared Decision Making @ Mayo Clinic:

A Culture Change Approach

Jon Tilburt, MD

SGIM Workshop Integrating Shared Decision Making Into Graduate Medical Education Denver, CO April 27, 2013

Organizational Context

• Fortune 100 corporation, 57,000+
• Large non-profit group practice
• Multi-state, multi-site
• Small medical school; big residencies
• Everything is centered around the practice
• Old fashioned medicine, 21st century

challenges

• “The Needs of the Patient Come First”
• Franciscan Values: dignity & service

The Example of St. Francis

• Sharing “good news” means

embodying a compelling message

Context: Human Capitol

• Huge workforce devoted to team
• “Lone Rangers” typically leave town
• EBM scholarship
• Ethics scholarship
• Risk prediction research
• Professionalism/Communication
• Institutional push to show practice

relevance

• Respected Sage/Guru/Prophet

Sage/Guru/Prophet

• @vmontori
• http://minimallydisruptivemedicine.or

g/tag/victor-montori/

Aphorisms: How to instill Change

• Work outward from your “spheres of

influence”*

• You can’t give what you don’t have
• Offer an appealing alternative
• Plan with values not base on “value”
• Exploit positive community norms
• “Magic School Bus” research

*Stephen R. Covey, Seven Habits of Highly Effective People

Living our values

How to Do it: Offer an appealing alternative

• Are underlying values of SDM there?
• “Be the change” (Ghandi)
• Rested, Flexible, Humble, Open-

minded, Forgiving

• “Constructively countercultural”
• Example: physical proximity
• Example: user-centered design

Appealing Decision Aids

• In-visit DAs
• http://shareddecisions.mayoclinic.org

/decision-aids-for-diabetes/Designer

• n the team
• Flattened hierarchy
• Iterative process
• URI

4 3

Flash

Where are we going?

• Expanding spheres of influence

(No short cuts to leadership)

• Expanding circles
• Coping w/bandwidth & burnout
• CME integration
• Thinking big

Resources

• Shared decision making national

resource [shareddecisions@mayoclinic.org]

Thank You

Tilburt.jon@mayo.edu

A Closer Look

3 Models of Resident Training

 Maine Medical –

Standardized patients

 Dartmouth –

Trigger Tapes, Video Decision Aids

 Mass General –

“Choice Reports”, SDM in Chronic Conditions

Using Standardized Patients to Teach Residents Skills in Risk Communication and Shared Decision Making:

The Maine Medical Center Experience

Objective: To develop curricular materials, teach, and evaluate residents skills in shared decision making in common clinical scenarios

Development

 Developed 2 cases

• CRC screening: decision to screen or not, and

use of colonoscopy vs FIT

• Mammography for breast cancer screening for

women in their 40s

 Trained Standardized Patients (SP)

• Concepts of SDM
• Issues we wanted them to bring up

 CRC: cost, prep, time off from work, risk  Mammogram: false positives, fear of not doing it

• Goals of the exercise
• Giving feedback using the OPTIONS tool

Logistics

 Residents received 5 minute introduction

• Update on screening guidelines, using pictograms to

explain absolute risk

 First case:

• Residents receive “door instructions” before entering

room with SP

• 20 minute SP event with 1st patient
• SP completes Options tool and debriefs 5 min

 Group debrief with faculty and SDM Talk focusing

• n the behaviors associated with SDM

 Second case:

• Same steps as first

 Final Debrief  Total time about 3 hrs

The Dartmouth Experience

Charles Brackett, MD, MPH

SDM in Primary Care

• Distribution of IMDF Decision Aids (7 of past 8 years)

– By “prescription”- ordered through EMR – Previsit delivery of cancer screening DAs

• PSA mailed to 50 year olds
• Pre-visit questionnaire

– Diabetes – Orthopedic referrals

• Clinician Training/Marketing

– Lunch talks – Emails – Exam room posters/references – SDM weblink in EMR (DA summary tools, risk calculators)

Residency Training

• Half day workshop for IM residents (11/09)

– Mix of didactic, trigger videos, and role play

• Impact Evaluated by analysis of audiotape of

standardized patient encounters in clinic at 1 mo and 6 mo after workshop (vs. control- RCT, n=41)

• Faculty: 3 lunch time talks
• Current: 1 hour with director of CSDM during

intern clinic orientation; role modeling

Didactic Content

• Background/Why is SDM important?
• Communication Skills

– Risk communication – Eliciting Values and Preferences – Recognizing and resolving decisional conflict – Checking for understanding

• Decision Aids

Lessons Learned

• Discomfort with uncertainty
• When is SDM appropriate?
• Initiating SDM: equipose
• Importance of faculty buy-in/training/role

modeling

• One page AF DA was popular

Resident training in SDM at Mass General

 Best methods for training and for

assessment are not yet known

 Chronic condition management

relatively under-studied in SDM literature

 Opportunity to study and apply SDM

to chronic condition management

Curriculum for residents

 Focus groups (elicit issues and

challenges with chronic condition management)

 2 hour training session

 Case study (baseline)  Training and introduction of methods

and tools (Choice Reports)

 Assessment (research study

component)

Tools for SDM conversations

 Choice Reports



Present options on a grid



Designed to facilitate conversation, not for stand-alone use



Pros/ Cons detailed



Option of “doing nothing” presented

 Choice Reports

developed for 4 target conditions:



Hyperlipidemia



Hypertension



Diabetes



Depression

Deep Dives

 Breakout groups – choose 2  15 minutes at each  Table 1: Maine Medical - OSCE  Table 2: Dartmouth – Trigger Tapes,

Video Decision Aids

 Table 3: Mass General – “Choice

Reports”, SDM in Chronic Conditions

Reflections

 Highlights?  Questions?  Concerns  Is there one new thing you can try

at your home institution?