{"id":9678,"date":"2011-06-27T14:25:33","date_gmt":"2011-06-27T13:25:33","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=9678"},"modified":"2011-06-28T15:00:07","modified_gmt":"2011-06-28T14:00:07","slug":"tessa-richards-prioritising-patient%e2%80%99s-views-reaps-rich-rewards","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2011\/06\/27\/tessa-richards-prioritising-patient%e2%80%99s-views-reaps-rich-rewards\/","title":{"rendered":"Tessa Richards: Prioritising patient\u2019s views reaps rich rewards"},"content":{"rendered":"<p><img loading=\"lazy\" decoding=\"async\" src=\"http:\/\/www.bmj.com\/site\/blog\/icons\/tessa_richards.jpg\" alt=\"Tessa Richards\" width=\"160\" height=\"111\" align=\"left\" \/>What will it take to persuade monolithic health systems to put patient\u2019s priorities at the heart of what they do? As researchers, health professionals, and patients debated this question at the <a href=\"http:\/\/www.isdm2011.org\">sixth international \u201cshared decision making\u201d meeting\u00a0<\/a>in Maastricht last week, the frustration was tangible. A survey to inform the meeting *reveals that while many countries are nominally signed up to initiatives to provide patients with the opportunity to participate in shaping services and making informed and shared decisions about their care. In practice, care on the ground is far from patient centred. Medical paternalism is alive and well.<!--more--><\/p>\n<p>Delegates pored over the reasons why shared decision making, which is widely seen as a cost effective intervention ( <a href=\"http:\/\/www.bmj.com\/content\/342\/bmj.d2117.full\">BMJ 2011;342:d2117<\/a>), is not being mainstreamed in clinical practice. Could the messenger be partly to blame? Some thought so. Over the past 20 years disciples of what might be described as the \u201cshared decision making\u201d movement have majored on ethics. Patients surely have the right to be engaged as partners in care, provided with information about the harms and benefits of tests and treatments, have their values and preferences elicited, and supported to make preference sensitive decisions. Maybe they should have talked more about the potential of shared decision making to cut costs, reduce unwarranted variation in clinical practice, and improve the quality of care.<\/p>\n<p>The money angle is certainly persuasive, particularly in the US where several states (according to the survey) have passed or are considering health care legislation that enshrines shared decision making and patient decision support. Dr Margaret Holmes Rover, from Michigan State University, cited an estimate that if the US Medicare Programme were to implement shared decision making using patient decision aids to help people make informed choices, it could save the programme $20.5 m per annum.<\/p>\n<p>Other perceived barriers to implementation of \u201cSDM\u201d were raised and many dismissed. Professor Victor Montori, a diabetologist, who is head of Knowledge and Evaluation Research at the Mayo Clinic in Rochester,\u00a0gave a bravura \u201cmyth busting\u201d address.<\/p>\n<p>\u201cI came to shared decision making from evidence based medicine,\u201d he explained, and the two are not inconsistent. \u201cEvidence from research is not enough, we must incorporate patient\u2019s values and preferences.\u201d Shared decision making models differ, he emphasised, and it\u2019s not about abandoning patients to make their own decisions. Decision aids are \u201cfun tools\u201d to help doctors work empathetically with patients, assess how much engagement they want, and then reach a shared decision. Working in partnership with patients rather than processing them through the health system \u201c brings joy,\u201d he said. \u201cIt makes you remember why you went into medicine the first place.\u201d<\/p>\n<p>Time pressure does not preclude the use of simple, well designed locally tailored decision aids in routine practice, he argued, and described the models used in the diabetic department in the <a href=\"http:\/\/kercards.e-bm.info\">Mayo Clinic<\/a>. Decision aids are also being used in the accident and emergency department, he said. \u201cPatients attending the acute chest pain clinic already have death on their mind and they value being given statistics about the pros and cons of being admitted to undergo further investigation and treatment.\u201d Giving information at this stage has, he said, resulted in a 50% reduction in admissions to hospital.<\/p>\n<p>Several speakers provided evidence, from rich and poor countries alike, to rebut the view some doctors hold, that patients don\u2019t want to be involved in decisions about their health. Research was also presented to suggest that with appropriate support, the old, seriously ill, and (health) illiterate can participate in decision making, and that there is little relation between what doctors think patients want and what patients really want.<\/p>\n<p>One example of previous work cited was of patients being given the choice to have low or high dose radiotherapy after prostate cancer surgery. Doctors assumed patients would trade side effects for improved survival, but the reverse proved true. (<a href=\"http:\/\/jco.ascopubs.org\/content\/25\/21\/3096.abstract\">doi:10.1200\/JCO.2006.07.4955<\/a>)<\/p>\n<p>Of course shared decision making requires a \u201cdemocracy\u201d of information and a shared electronic record, which enables a two way conversation was, delegates agreed,\u00a0 one of the most effective ways to promote the process.\u00a0 Eliciting patients views can also stimulate innovative service design, said Dr Jan Kramer, a Dutch gynaecologist, head of the IVF clinic in Nijmegen. His department has been \u201crevolutionised\u201d by talking to patients and understanding their priorities, and it has resulted in\u00a0 \u201cmore trust between clinicians and the patients and fewer complaints.\u201d Manning a virtual chat room to answer patient\u2019s questions had not been time consuming, and it had paid dividends by reducing consultation rates.<\/p>\n<p>Given the evidence on the quality and cost effectiveness of care there is surely a case for more health professionals and policy makers embracing the shared decision making movement. After all, most of our health care systems are broke and we are all likely to end up as patients one day.<\/p>\n<p>*German journal for Evidence and Quality in Health Care. 4.105.Jahrgang 2011. Policy and practice developments in the implementation of shared decision making: an international perspective.<\/p>\n<p><em><strong>Tessa Richards<\/strong> is analysis editor, BMJ.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>What will it take to persuade monolithic health systems to put patient\u2019s priorities at the heart of what they do? As researchers, health professionals, and patients debated this question at [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2011\/06\/27\/tessa-richards-prioritising-patient%e2%80%99s-views-reaps-rich-rewards\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1751],"tags":[2382],"class_list":["post-9678","post","type-post","status-publish","format-standard","hentry","category-tessa-richards","tag-shared-decision-making"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Tessa Richards: Prioritising patient\u2019s views reaps rich rewards - The BMJ<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmj\/2011\/06\/27\/tessa-richards-prioritising-patient\u2019s-views-reaps-rich-rewards\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Tessa Richards: Prioritising patient\u2019s views reaps rich rewards - The BMJ\" \/>\n<meta property=\"og:description\" content=\"What will it take to persuade monolithic health systems to put patient\u2019s priorities at the heart of what they do? 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