SAN DIEGO—At the ACR/ARHP 2017 Annual Meeting Nov. 3–8, a session on how to promote shared decision making with patients highlighted the role of the multidisciplinary professional team. And perhaps just as importantly, it noted the importance of providers recognizing their own implicit biases, which can get in the way of shared decision making.
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Presenters from the Hospital for Special Surgery’s Department of Social Work Programs in New York City described a process of collaboration that allows patients and providers to make treatment decisions together as a dance, taking into account both best clinical evidence and patients’ values and preferences. “But sometimes patients are doing a different dance than we are,” said Jillian Rose, LCSW, assistant director for Community Engagement, Diversity and Research at the hospital.
“Look at the waltz of shared decision making as an opportunity for intervention. Start where the patient is. How can our patients play a greater role in their care?”
To better involve the patient, Ms. Rose suggested shifting the focus from, “What’s the matter with you?” to “What matters to you?” That kind of decision making can lead to better patient outcomes, including better understanding of their condition, reduced anxiety, increased satisfaction with treatment decisions and greater willingness to undergo treatment.
Other steps to promote shared decision making include presenting options to patients, using decision aids, providing information on both benefits and risks, and helping patients evaluate options based on their goals and concerns. In other words, incorporate the patient’s perspectives into the conversation.
“With the move toward more patient autonomy and the explosion of technology, patients are having conversations about their healthcare decisions on social media, with Facebook friends, on Twitter chats and with peers. If we don’t involve the patient [in the conversation], we’ll be left out of providing invaluable information to our patients that can influence their care and lead to better outcomes,” Ms. Rose said.
Barriers to shared decision making include lack of time for busy clinicians, perceived threats to the power relationship between doctor and patient, lack of communication, lack of trust and patient characteristics that can lead providers to form conclusions that get in the way of collaboration.
The time we think we are saving by not soliciting and including the patient perspective will be lost if our decision making lacks patient buy-in. This can lead to non-adherence to the treatment plan; patients can be lost to follow-up, sometimes ending up in emergency departments with worse outcomes. “The first step in achieving shared decision making with patients is checking our own biases to ensure we are not unconsciously making recommendations based on our agenda, values and stereotypes,” Ms. Rose said.
Your Implicit Bias
The concept of implicit bias posits that we all have attitudes we aren’t consciously aware of, which can affect our understanding, actions and decisions in an unconscious manner. Such bias impacts the quality of the clinical interview, diagnostic decision making, treatment recommendations and referrals to specialty care. Other core issues impacting patient participation in decision-making discussions include race, culture and ethnicity, perceived power differentials between patient and clinician, and lack of empathy or receptivity by the provider.
Hidden biases can cause inequities in care, and health disparities and their consequences have been well documented by the Institute of Medicine and others.1 Research suggests implicit or hidden biases by healthcare providers help cause disparities, leading to adverse treatment and less quality for some patients.
Providers must know about their own implicit biases and barriers to communication in order to overcome them, Ms. Rose said. “Implicit bias provides a lens for viewing this dynamic. Attitudes people aren’t consciously aware of can impact the care they provide. It affects all of us.”
Environment of Empathy
Another presenter from the Hospital for Special Surgery, Adena Batterman, LCSW, MSW, senior manager for inflammatory arthritis support and education, encouraged providers to create an environment of empathic care as the foundation supporting a spirit of shared decision making. She emphasized that patients, too, are experts in their own illness experience, background and values. Treatment discussions, therefore, require two-way information exchange, which explores who the patient is in the context of their life and experience.
“In the monthly support and education program we developed for people with rheumatoid arthritis, we hear about patients’ perspectives and feelings about their illness and treatment and how they impact their coping with illness,” Ms. Batterman said. They include fear of medications and beliefs about them, symbolic meanings for patients about taking medication, and the meaning of having a chronic illness. Also, many patients are overwhelmed by information and lack self-efficacy, or have low health literacy. In order for patients to participate in decisions, providers must identify and consider these issues. While some patients clearly communicate these concerns in medical encounters, others only give subtle cues, and providers must be attuned to them, she said.
“Like our patients, we bring a complex interplay of experiences and feelings to every encounter, which impacts our decisions,” Ms. Batterman said. “We’re trained to cure, but what if we can’t?” she added. “It’s important to understand the impact patient loss can have on providers and how that affects our ability to provide empathic care.”
One effective tool: mindfulness training, which is a way of thinking that enhances focus and clarity despite the pressures of a busy day, helping clinicians listen more carefully to their patients, show compassion and approach problems in a fresh, open-minded way.
Assess Mental Health Issues
A further layer of complexity to patient communication involves considerations of mental health issues patients may bring to their encounter with the rheumatology team. Joan Westreich, LCSW-R, social work coordinator for the hospital’s Early Arthritis Initiative, said depression, anxiety and other mental health issues can impact patient–provider communication, the patient’s engagement with treatment, adherence and other outcomes.
The association between depression/anxiety and rheumatologic conditions is well documented at about double the rate of the general population.2 That makes it imperative to routinely assess for mental health concerns in rheumatology patients.
“What might we learn about our patients that we don’t already know? What impact would this knowledge have on our ability to deliver patient-centered care?” Ms. Westreich said.
What’s the impact of not evaluating patients for mental health issues? Depressed patients may have trouble taking in information. If providers screen for depression and anxiety, they also must know when to collaborate with other specialties for further assessment and treatment.
A diagnostic interview is the gold standard for assessing mental health issues, she said. But screening tools and assessments such as the Patient Health Questionnaire (PHQ-9) and its short-form two-question assessment tool can give clinicians a better sense of when to refer for a mental health consult. Providers can obtain other shared decision-making resources from the Mayo Clinic Shared Decision Making National Resource Center, the Dartmouth Center for Shared Decision Making and the Minnesota Shared Decision-Making Collaborative.
Larry Beresford is a freelance medical journalist in Oakland, Calif.
- Institute of Medicine (US). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: The National Academies Press (US). 2001.
- Matcham F, Norton S, Scott DL, et al. Symptoms of depression and anxiety predict treatment response and long-term physical health outcomes in rheumatoid arthritis: Secondary analysis of a randomized controlled trial. Rheumatology (Oxford). 2016 Feb;55(2):268–278.