Shared Decision Making in Family Medicine

Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847 1 / 18

Our experiences as patients: did you ever feel powerless?

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Objectives

• At the end of this session the participants will be able to; – discuss the definition of patient empowerment – discuss the status of patient empowerment in FP – explain the need for patient empowerment – explain the power/relationship graph – discuss the reasons of powerless patients – explain how to empower patients 3 / 18

What is it?

• an individual being an active member of his/her disease management team Laura E. Santurri. Patient Empowerment: Improving the Outcomes of Chronic Diseases Through Self-Management Education. http://www.case.edu/med/epidbio/mphp439/Patient_Empowerment.htm

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The idea behind

• Patients cannot be forced to follow a lifestyle dictated by others. • Preventive medicine requires patient empowerment for it to be effective. • Patients as consumers have the right to make their own choices and the ability to act on them 5 / 18

Why Patient Empowerment?

Remember the “patient centered clinical method” • Evaluating both the disease and the illness experience • Understanding the whole person • Finding

common ground with the patient

about the problem and its management • Incorporating prevention and health promotion • Enhancing the doctor-patient relationship • Being realistic 6 / 18

Why Patient Empowerment?

• • Only 9% of consultations with surgeons and primary care physicians meet full criteria for informed decision making.

Braddock JAMA 1999

• Distinguishing elements of shared decision making occurred in 0-11% of audio taped patient interviews with general practitioners.

Elwyn 2001 “..

Checking of understanding, and the involving of patients in decision making .. are rarely demonstrated” [in video taped consultations submitted for MRCGP examination].

Campion BMJ 2002

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Why Patient Empowerment?

“People whose lives are affected by a decision must be a part of the process of arriving at that decision.” –John Naisbitt,

Megatrends

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Keep

The Power/Relationship Graph

Power

Share

Relationship

Transaction Partnership http://ejc.sagepub.com/cgi/reprint/19/3/417.pdf?ck=nck 9 / 18

Problem Solving

Keep

Impose Dictate Power

Share

Compromise

Transaction

Common ground Relationship

Partnership 10 / 18

Countries

Keep

USA Power

Share

China UK Italy Middle east Japan France Russia Germany Sweden Relationship

Transaction Partnership 11 / 18

Why is the concentration of power in this relationship with physician?

• Education • Professional status/authority • Knowledge • Skills • Expertise • Experience • On familiar territory • GATEKEEPER TO HEALTHCARE SYSTEM 12 / 18

Why is the concentration of power in this relationship with physician?

• Patient is sick, weak, vulnerable, not feeling fully oneself… • Patient may be afraid • Patient in a state of dependency • Lack of medical knowledge • Lack of knowledge on the “system” and how it works • Unfamiliar environment 13 / 18

Benefits of Patient Empowerment

• • • Learning from our patients Taking a proactive role Providing a support & information service to our patients and staff • • • Complaint Resolution Negotiation & Mediation Building trust 14 / 18

Presenting concern “patient’s story” Model for Clinical Problem Solving & ISDM Hypothesis Step 1 Identify choices DOCTOR - PATIENT COMMUNICATION Establish pt’s role in decision making

Step 2

History and physical exam Review pt’s preference for information

Step 3

Identified problem or diagnosis

Step 4

Present evidence Respond to pt’s ideas, concerns and expectations re: management

Step 5

Management / treatment Assess partnership (review previous steps)

Step 6

Follow-up Negotiate a decision

Step 7

Agree on an action plan

Step 8 15 / 18 *ISDM: Informed Shared Decision Making

Disempowered Not involved No dialogue No Voice in the System Feeling vulnerable No Partnership

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Some useful hints before finishing

• The skilled family physician can spend 10 minute with a patient and the patient feels it was 20 minutes • Even the busiest physician can accomplish wonders in a few minutes by indicating that their full attention is on the patient • Please conclude every interview with the statement “is their anything else bothering you that we have not discussed?” • Rather than assuming that the patient have understood the instructions, ask them to repeat as they understood • Use the patients name or ask him what he prefer to be called as • Use “how can I help you? Rather than “what brings you here today?” 17 / 18

Empowerment allows our relationships to grow in strength

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