Within the practice of rheumatology, we have multiple opportunities to exercise shared decision making. Our practices include many patients with chronic diseases. We are able to forge trusting relationships that may last decades. And we offer a smorgasbord of therapies ranging from nonsteroidals to corticosteroids to cytotoxics to biologics. This cornucopia of choice lends itself to patient empowerment as rheumatologist and patient jointly navigate through the options.
I frequently say to my patients, “Think of me as your waiter. My job is to describe what’s on the menu. Your job is to choose.”
Many of my patients, however, prefer to avoid the responsibility of making a decision. “Doc, what would you do?”
Even in an idealized interaction with an engaged and knowledgeable patient, is it really possible for a physician to be neutral in the shared decision-making process?
Reality Check
A recent publication suggests that rheumatologists fail at shared decision making.
The study examined how a change in Medicare reimbursement policies might affect the frequency of prescribing specific biologic therapies.1 The authors tested the hypothesis that the recent provision to cover self-injected TNF inhibitors would increase the rate that this class of medication would be prescribed. They were also expecting to see a concomitant decline in the number of prescriptions for intravenously administered TNF inhibitors. However, no decrease was observed in the Medicare-eligible population. Instead, the study found that the preference for an infused drug was strongly related to physician reimbursement. This observation can be interpreted in several ways, but perhaps the most straightforward conclusion is that the practice of shared decision making in this area is being influenced by a financial bias that can be either conscious or unconscious.
Patient Example 2
Mollie is bright, determined and resilient, qualities that have served her well for nearly 80 years. She also has severe rheumatoid arthritis (RA), which has been complicated by small vessel vasculitis and peripheral neuropathy. I hope that I have provided her with excellent care in monitoring a therapeutic regimen that includes methotrexate, hydroxychloroquine, sulfasalazine and a biologic drug. But Mollie also has chronic obstructive pulmonary disease. About twice a year, she develops a respiratory infection, requiring antibiotic therapy and a temporary halt to her immunosuppressive regimen. Finally, Mollie has decided that the punishment—her medications—is worse than her disease. She decided to stop methotrexate and her biologic therapy. After discussing this wish, we jointly agreed that she can try this approach. However, I suspect that within a few years my compensation will depend on meeting treatment standards—one of which will include treating all patients who have severe, erosive RA with a disease-modifying antirheumatic drug. Using this standard, I would be penalized for embracing shared decision making, just as I would be docked if my patient with hypertension insisted on being treated with naturopathic remedies.
Perspective
When my younger daughter was an adolescent, she reminded me on a regular basis that I was going bald. And every day I would look in the mirror, see a full head of hair curling above my forehead and conclude that my daughter was just experiencing adolescent rebellion. The mirror never revealed to me the rapidly enlarging bald spot at the rear of my skull. My insight was imperfect.
