A variety of other decision support interventions are available, summarizing information in ways easily accessible to patients. These may be brief text or diagrams, or longer, in the form of booklets, DVDs or websites.12 The Mayo Clinic offers a variety of shared decision-making resources, as well as a helpful decision-aid tool for rheumatoid arthritis.
Barriers: Time
In the real world, shared decision making often runs into practical barriers. Dr. Desai sees time as one of the key issues preventing some clinicians from using shared decision making. “If they are a new patient, and you also want to diagnose them and even start them on a treatment, that is really hard to do in 40 minutes in an effective way. The shared decision making takes time, and it often takes more than one visit.” In a brief office visit, clinicians may not feel like they have time to discuss what is most important to patients about their life goals. Unfortunately, existing reimbursement systems provide incentives for short office visits and little financial reward for shared decision making.10
Many patients wish to learn more about their options before making a decision, and they want time to discuss their options with family members or friends.6 If possible, practitioners should recognize this need and find ways to accommodate it into their practice.
On a systems level, Dr. Desai notes that in some settings, the process of shared decision making may best be implemented through a follow-up visit via telemedicine, after the patient has had time to become educated about their options and consider their values and preferences. Ultimately, new systems may be needed to make time for truly shared decision making and to reward clinicians who engage at that level.6
Barriers: Patients
Changing the patient/provider communication dynamic will require changes on the part of patients as well. Dr. Cozad and her colleagues are currently accruing data for a project encouraging patients to bring their goals and priorities for care to the clinical encounter. They have created a tool that asks patients questions about their lives and the major symptoms and side effects they would like managed. The tool turns their answers into a graphic that can then be used to share information with their medical provider in a streamlined fashion. “Hopefully, by using that graphic, they can talk about it with their rheumatologist and then improve treatment adherence,” says Dr. Cozad.
Dr. Cozad believes this approach is empowering to patients who may feel bound by the old paternalistic model of medicine. “We wanted to change that mentality and get our patients to realize that by voicing your priorities, preferences and goals, you are more actively participating in your care, and the more actively you participate in your care, the better we can take care of you.”
