August 2002 Bulletin

Shared decision making

Key to health care reform

By James N. Weinstein, DO, MS

As orthopaedists, we need to ask our patients how we can play a greater role in their care and in decisions about their care. We must also ask if patients should play a role in pursuing and maintaining good health rather than relying on the "quick fix" after neglecting their own intrinsic responsibilities.

Other questions arise. Does the ability to perform high-risk procedures exceed our current ability to understand and deal with the aftermath or problems that we create, despite our intentions to do well for all the right reasons (e.g., treating patients with infertility in light of possible multiple births; performing bone marrow transplants for patients with breast cancer)? What are the right answers, and who should decide—the system, the government, the doctor or the patient?

Who decides?

From the point of view of the individual patient, there is another, equally important, question: who do I want to make my health care decisions for me? For generations now, we have thought that we knew the answer to that question: our trusted doctor would decide. But the answer is not so obvious anymore; it is confounded by other questions: Whose preferences matter more? In situations of uncertainty about the best way to manage a given condition, whose preferences should prevail? Are more care, more intervention, more hospitalization and more screening better than less?

We fear now that these decisions will be made by insurance companies, rather than doctors. I suggest that the proper response is to let patients decide whenever possible. A small but growing body of research is telling us that patients actually want less than we are giving them, and perhaps one way to temper our addiction to doing everything is to let patients tell us when they have had enough.

As an industry, we have acted very paternalistically, much like the Big Three automakers in the bad old days, the 1960s and 1970s, when Americans began to prefer small, reliable Japanese cars over the large, less reliable products of Detroit. The American auto industry continued producing cars that few people wanted. Right now, the health care industry produces one model: the "Fix-it," with questionable features such as hospitalization for the dying process and vast programs of screening for pseudo-diseases that do not require treatment.

This kind of thinking does not work in business or health care. Successful companies are service-based and customer-oriented. They sell customers what they actually want to buy. Customers, or in our case, patients, want quality, convenience, respect for their beliefs and a price that reflects what they are willing and able to pay.

Medicine, of course, is not as uncomplicated as cooking hamburgers or delivering packages. However, health care providers who do not want to find themselves with the medical equivalent of fleets of unsold cars must find better ways for patients to participate in decisions about their own health care. Patients do not want "do-it-yourself" health care, but they do want to understand the alternatives; they do want to be informed and they definitely want choices.

Shared decisions

One answer to the challenge of meeting patients’ needs (or, in business terms, having customer focus) is shared decision making or informed choice, involving the patient and the physician in choosing among available options. Increasingly, patients want to be empowered, to have some measure of control over, or at least participation in, the decision making process. Patients who participate in decision making have more confidence in the decision itself, because it incorporates the "expert" opinion of the physician with the patient’s own preferences.

As patient interest in knowing more and becoming more involved in medical decision making grows (and there is good evidence that it is growing), offering shared decision making gives providers a strategic advantage. In an environment where it is becoming increasingly difficult to operate profitably under old models, shared decision making is an opportunity to do the right thing while creating a competitive advantage.

When we ask, "Who is going to make your health care decisions?" we should take into account the available evidence about the effects of decision making that is not shared. If, pursuing our metaphor of shared decision making, we ask the scientific community to measure and report on the effect of current practice, we find that medical decision making as it now exists is highly variable: rates of procedures, hospitalizations, diagnostic tests and reimbursements are quite idiosyncratic.

As Uwe E. Reinhardt, a respected writer and speaker on the economics of health care, who serves as a member of many prestigious health care committees, including the Council on the Economic Impact of Health Reform, the Committee on Technical Innovation in Medicine and the National Leadership Coalition on Health Care, has said, "Not every rate can be the right rate." If these variations exist, they exist because we created them. If they are to be rationalized into some kind of system of care where our patients and we make explicit choices among known outcomes, we must involve our patients in choosing. The evidence shows that giving patients a preference for treatment can affect rates of surgical procedures and can narrow the variation. The rate that we create with our patients’ involvement and according to their informed preferences will be the "right" rate.

Shared decision making is not a cure for all the system’s ills, and in many instances there are significant barriers to its successful implementation. On the other hand, shared decision making is not an uncharted course. Others have experienced this weather and can teach us how to navigate. The experience of shared decision making trials can even help predict what the effects of broader implementation would be. And the news is good. Shared decision making has been well received by patients who have used it, and it appears to enhance patients’ ability to make decisions that are congruent with their real preferences. A diverse group of health care delivery systems have tried this approach with consistent results: satisfied patients who choose the less-invasive approaches to care than are prescribed for patients under other models of decision making. More studies are needed to confirm the efficacy of the shared decision making model, but the principles have been established as valid.

Missing piece

If there is, as we anticipate, money to be saved by following this option with the least associated risk (the preference of the large majority of informed patients), then that money could be used to provide for unmet needs, such as basic care for the uninsured or prevention programs that could lower the risk of disease, resulting in even more savings. The doctor-patient relationship must be based on trust, compassion and the best knowledge medicine has to offer. The health care "market" must be patient-focused and patient-driven.

The "missing piece" in health care is the patient’s desire and ability to make decisions when well informed. Shared decision making provides a technology to provide our patients with this "missing piece." Shared decision making is a piece, which, if implemented, has the potential to improve our nation’s health dynamic. How this is best done and who should make it happen are the issues that stand between its success and its failure. Our patients deserve and want better health care; with shared decision making and choice, there is hope.

Note: The AAOS is addressing this issue through its Shared Decision Making Task Force, which is chaired by Andrew J. Weiland, MD. The goal of the task force is to develop a shared decision making program for patients who are facing treatment decisions regarding osteoarthritis of the knee or the hip. For more information about this work in progress, contact Robert Fine, JD, CAE, AAOS director, health policy department, at (847) 384-4322 or at fine@aaos.org.

James N. Weinstein, DO, MS, is the professor and chairman of orthopaedics and Community and Family Medicine at Dartmouth Hitchcock Medical Center in Lebanon, N. H., and Dartmouth Medical School, Hanover, N.H. He is the editor-in-chief of Spine.

Adapted from "The Missing Piece: Embracing Shared Decision Making to Reform Health Care," Spine, 2000,Vol. 25:1, pp 1-4.


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