By Scott Harris
Doctors and the delivery system are constantly changing these days. But so, too, are patients, and the groups don’t often change in perfect congruence.
One exception is shared decision-making, or SDM, a general term for a method of clinical communication that works to make care decisions a joint effort between patient and provider. It’s becoming more important in a post-Affordable Care Act, post-WebMD world, in which patients are better informed and more empowered, and it’s being worked into at least one medical school curriculum.
“Shared decision-making bridges the clinical and communication realms,” said Cathleen Morrow, MD, pre-doctoral director at the department of community and family medicine at Geisel School of Medicine at Dartmouth. “It helps [doctors] identify what type of care is evidence-based care, and what kind of care is preference-sensitive. The best informed patient is one presented with options and helped by a physician to make a decision.”
According to Jean Slutsky, director of the Center for Outcomes and Evidence at the Agency for Healthcare Research and Quality (AHRQ), the Affordable Care Act does include sections related to shared decision-making, although to date the provisions have not received any funding from Congress. AHRQ currently has public web pages that help guide clinical decisions for osteoporosis and localized prostate cancer, with plans to develop more pages for additional conditions.
“Care decisions are increasingly complex, with more innovations and more options,” Slutsky said. “A shared decision means more to the patient and their quality of life.”
It is always challenging to pack anything new into the medical school curriculum. Leaders at Dartmouth, with help from a grant provided by the Health Resources and Services Administration, developed and implemented a mandatory six-week course for third-year students in the family medicine clerkship, embedding didactic and experiential learning. Morrow said the addition was not easy, but can be done flexibly.
“It’s not just a plug-in. You can’t just do a single-hour lecture,” Morrow said. “We begin by exposing students to it in the first and second years. They hear the language, and then there is full immersion in the family medicine clerkship. We show lots of routine cases that they will see during their rotations.”
At the University of North Carolina at Chapel Hill School of Medicine, medical students who are also pursuing a master of public health degree receive education on SDM through the “Communication for Health-Related Decision-Making” course. The course focuses on different methods of communication, with students talking through potential strategies in various real-world examples, then learning the tools to follow through on those strategies.
“We teach students how to decide on a way to communicate with someone,” said Stacey Sheridan, MD, a professor with UNC’s Gillings School of Public Health, where the course is taught. “We discuss different approaches, then follow up with skill-building lectures and exercises.”
Shared decision-making is gaining traction across the system not just because it can improve communication or patient satisfaction, but because it makes medicine more effective.
“If you just tell a patient what blood pressure medication to take, and they say ‘Yes, doctor,’ they might leave and not do it, or it might not be the right course,” Morrow said. “What are some other reasons the patient’s blood pressure is high? What is their insurance status? Can they afford the medications? Shared decision-making involves recognizing there are two experts in the room: the doctor, who knows the medical content, and the patients, who know themselves.”