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 outcomes  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

A word on taxonomy  Effective care  Strong evidence base supports care SDM  Benefit to harm ratio high Sweet Spot  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 R. Wexler, FIMDM

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 )

Decision Aids Can Help  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: 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, 21 st 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 on the team • Flattened hierarchy • Iterative process • URI

Flash 4 3

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 1 st patient • SP completes Options tool and debriefs 5 min  Group debrief with faculty and SDM Talk focusing on 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)