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Victor M. Montori, MD, MSc, discusses decision making and the patient.
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Victor M. Montori, MD, MSc, discusses decision making and the patient.
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[ Music ] >> This is Gordon Guyatt. I am one of the Editors of the "User's Guide to the Medical Literature." And this morning I'm going to be talking to an author who's been very prominent in the "User's Guide to the Medical Literature" in a number of the chapters of the book, and the leader on one of the chapters that deals with shared decision making.
And that is Victor Montori who's a professor at the Mayo Clinic. Victor, welcome. >> Thank you, Gordon, a pleasure to be here. >> Let's jump right in then with the topic of shared decision making. And of course, we're interested in shared decision making in the context of evidence-based care. How does shared decision making advance evidence-based care? >> When one thinks about evidence-based care, one has to remember that there are several principles, of course one of which is that you make decisions on the basis of the body of evidence, that not all evidence is created equal and there's a hierarchy of evidence in terms of the confidence that one derives in the estimates of effect whether it's a harm or benefit.
But then it's evidence-based care. It's evidence-based medicine. And to care for people one has to make sure that the tests and treatments that one is going to use make sense intellectually, emotionally, and practically to the people we're trying to help. That's why in evidence-based medicine there is a principle that the evidence alone never tells you what to do, that you have to consider if one were to be standing from the clinician's perspective, one has to consider the context, the values, and preferences of the patient.
I deal mostly with patients with chronic conditions, and oftentimes they are in charge of enacting their own care, organizing it, and making it work in the context of their lives. And one could easily say the same thing from their perspective. As patients decide how they're going to care for themselves, they would want to incorporate the experience, expertise, and evidence that the clinician offers in the context of their lives and in the context of their own values, preferences, and goals. How might we achieve that? How do we get to find out what makes sense in the lives of people?
It is with their participation. It's with their involvement. And by considering and working through with them what aspect of their situation requires action, and then figuring out together what action does the situation require, a dance that we sometimes call shared decision making, we can ensure that not only are we using the best evidence, but the care that comes out of that and is decided upon makes sense in the life of people. >> Now many clinicians, maybe virtually all clinicians nowadays, provide care considering clinical practice guidelines to which they are exposed.
How do we square shared decision making with the clinical practice guidelines that are telling physicians how to manage their patients? >> Clinical practice guidelines often give strong recommendations. Unfortunately, sometimes too often. And strong recommendations sometimes have been described as just do it recommendations. Those I think work the best when they are mostly don't do this recommendations because in that situation it keeps patients safe.
For treatments that for most patients it would make sense to enact and to use them, to implement them, because they're most likely to do more good than harm, and there may be strong recommendations in favor of them, if the intervention requires patients to implement them in their lives say through adherence to therapy, then it is problematic to have a just do it recommendation without taking into account the conditions of living that patients have. And so even in strong recommendations and just do it recommendations in favor of interventions in which patients are responsible for the safe implementation of an intervention in their life it is very important to use shared decision making to make sure that for this patient the general recommendation applies, that in their context they can implement that, and to figure out if they need additional support to do it in a safe manner.
For other recommendations, further suggestions, or weaker conditional recommendations, there is a built-in room for consideration and discussion of specific circumstances of people. And among those circumstances, among the biological issues that clinicians may consider, there will be psychological and social issues and issues of preferences and goals that must be taken into account in configuring a treatment program for patients. So for most patients in the context of current guidelines, when those guidelines are well developed, strong recommendations in favor of interventions they have to implement in their lives, the implementation of those may require involving patients in making sure that they can safely do so.
And for conditional recommendations, it is essentially the best way to implement those recommendations to have those discussed with patients and work through together what are the issues and make sure that those recommendations, which are written for people like them, result in the right treatment for this person. >> Well, I'm wondering if there are situations when evidence-based care can happen without involving patients in decision making. For instance, are you seriously suggesting that a patient comes into emergency with a clear myocardial infarction, and you start a shared decision making exercise about whether they should receive aspirin or not?
>> Am I seriously suggesting that? Are you seriously asking that question? [ Laughter ] I think that -- I think that our primary job as health professionals is to take care of people. And the circumstance often dictates what is possible, is feasible, and what's desirable. I think as a general rule we do not do things to people without their authority or their authorization. That's the basis of informed consent. But when the situation opens up and the urgency allows and there is value beyond let's call it political correctness, when there's value in terms of determining what exactly fits better in this patient's circumstance, I favor that conversation.
Now we have to recognize, and this is not in the book because this I think has been worked out after the publication, that there are multiple purposes of shared decision making. The original version was about choosing. It was about opting between doing or not doing or between option A and option B. But there are other forms of shared decision making that are related to patients with chronic conditions, for instance, in which what is sorted out is not really what you want or what you prefer, but really what is the right solution to the problem the patient's facing at the moment.
So solving problems together sort of action in which we're making decisions. People who work in the hospital, for instance, do this all the time when they conduct their discharge planning rounds where nurses, family, and clinicians sort out when and with what arrangements patients are going to leave the hospital. And that is an exercise in shared decision making in which it's less about what you want, and what choices you make, but more about solving problems. And similarly, in the situation of a patient at the end of life when they are looking at writing their last chapters in their own books, oftentimes particularly folks with limited experience show up at the bedside and offer patients choice.
You know, would you like to do CPR or not? Would you like ventilation or not? And all of a sudden, the patient is faced with a menu of things that they can opt in and opt out. And that comes across as uncaring and formulaic and procedural when, in fact, what you want to do is care for those folks. There is a form of shared decision making in which you're sorting out these more transcendental issues with patients that have nothing to do with choosing or selecting and more to do with again trying to make sure that the last chapter in your life is written with the same ink as you've been writing the other chapters as you were living.
>> I work in hospitals and so I'm regularly sorting out at the time of admission a patient's code status. You suggested that if I just go in and address this directly perhaps in the way I'm doing that I'm at risk of coming across as uncaring. How should I be doing that? >> We've all seen people who are a little bit too rushed, a little bit trying to check the boxes and move on to other tasks, who may for the first time bring up the issue of death as a possible outcome of this hospital admission.
For this otherwise young person perhaps admitted with a severe [inaudible] or something of that nature. And all of a sudden somebody walks in, usually the least experienced member of the team, and is asking the patient about, "In the event that you die, what would you like to have happen?" And yes, that comes across I think often as very uncaring and again formulaic. There are multiple ways of handling this. I think, you know, one of the ways, for instance, our group has been dealing with these sorts of issues is to conduct research into how might we do shared decision making in different circumstances.
For instance, when elderly people get admitted from nursing homes into the emergency room because they have suffered a -- some deterioration, it is oftentimes those same people who may have expressed in a previous admission to hospital that they don't want to come back. So in the emergency room we have now tested a small tool that shows trajectories that patients may follow as they get admitted to hospital with problems when they're quite elderly. And so then that allows the emergency room doctor to talk to the patient about what is desirable in this trajectory.
Is it alleviation of the discomfort and return to the nursing home for further care? Is it alleviation of the discomfort and admission to the hospital to work through it? And so forth. And it's not in the answer that the care arises, but rather in discovering from the discussion of those things what matters to the patient, and in the clinician working through creatively with the patient to honor what seems to matter to them and what kind of care might work best for them. This is in contrast with the approach of we don't have beds, we have beds, we better send you back, do you want to be admitted, and you want people to intubate you and pound on your chest.
When we look at the videos of the discussions that people are having today you wouldn't use the word care necessarily to describe it. And I think it's unintended, but that's what it comes across. >> Have I got it right? It's having the conversations in a respectful and caring way that attends to the patient's needs at the time. Is that the basic message? >> It is a big part of it. I think not only just respectful, but I would add curious.
I think we sometimes because of urgencies and speed and other things, we don't give ourselves the opportunity to dig deeper into understanding the person in front of us. And I think this idea of uncovering or figuring out their values and preferences, it's really a bit of an adventure in understanding the person that is behind a diagnosis or behind the bed number in front of us. And it's in discovering that person that we work together to -- and again usually the right answer emerges from that discussion.
It becomes clear. And it requires respect, but it also requires curiosity and compassion and a real willingness to really help this person out. It is when we stop seeing individual people in front of us, and we start seeing a patient with AFib or a patient with MI or a patient with a diagnosis, and we start treating them as a member of a class that although standardization comes on, which is sometimes helpful to keep people safe, we lose then the opportunity to individualize care in a manner that is both scientific, it's evidence-based, and is also appropriate for who they are.
It's respectful of their situation. It's kind. >> Yeah. I've picked up from conversations before this caring element that is undoubtedly crucial, but I find it intriguing and interesting the element of curiosity about finding out who the person is. I really like that. I'm often after having the conversations with the patients documenting some aspects of their preferences on the chart. What are your thoughts about what after such conversations, about what should be put on the chart or what is necessary to put in the chart, and what may not be necessary?
>> That's a great question. So a couple of things about that. One is the chart today plays kind of a series of roles in care. In the United States where I work, the chart is mostly a documentation for billing sort of tool. And so most of my colleagues I think as a matter of reflex rarely read what's on the chart. There are however a lot of initiatives to document in the chart goals of care, priorities of care, values, preferences. And it seems to me that it is an exercise in extending this engineering approach to healthcare where if you just document this, then care will sort of adhere to it or be consistent with it.
I think the important part of documenting might be the eliciting and the important part of the eliciting might be that exercise in creating a moment of connection, of deep human connection, between the clinician and the patient. So the clinician gets a chance to know who they're caring for, and the patient gets a chance to develop a similar relationship that might help with trust and the old therapeutic alliance that sometimes is so important to help people recover. So I'm not obviously a big fan of documenting in sort of a checklist or in sort of a non-narrative way.
Oftentimes I also find it very hard to describe people's preferences once you pick them up, to describe them in simple terms. If that is possible, then of course it might be helpful to contribute to teamwork if other members of your team have the same awareness that you have with all the work that you've done in figuring out what makes sense and what matters to this person. But I would be quite concerned of initiatives that have as an outcome the documentation of preferences because I'm afraid what we will do is we'll make a system that consistently achieves a documentation and nobody will know who the patient that completed that form, that led to that documentation, truly is.
>> What about the tangible benefits of shared decision making? Improving adherence to treatment, lowering costs, improving health outcomes. What are the benefits of shared decision making in those aspects? And if there's not much evidence shared decision making does something in those areas, why the big deal? >> So I'll start with the bottom line, and the bottom line is that shared decision making has not been shown to consistently improve disease control, disease outcomes, treatment adherence for therapy, resource use, intensity or invasiveness of interventions, overall costs.
None of that stuff. Actually, there's not even a consistent finding in saying that shared decision making takes more time. First of all, why is it that we have no consistent evidence of these things? And if it cannot do any of that, then why the big deal? So I'll start by telling you that I think that there are multiple forms of shared decision making that most of the ones that have been tested are of the kind where patients are given information and then sent to the battleground of discussing with their clinician.
It's almost like a defensive action against the clinician who is going to offer surgery or is going to offer treatment. By preparing the patient for that conversation, the expectation is that the patient and the clinician will have a shared decision at the end. The best evidence suggests that when you educate or train the patient and then send them to have a discussion with the clinician, and the clinician knows that they've received that training, the clinician will verify that the patient understood the information by maybe asking a question, and then will ask the patient what they would like to do.
And so it becomes not a shared decision, but in fact it becomes what people call an informed decision which is when patients make the call and clinicians follow. The most likely scenario has been tested. There's been more than 100 randomized trials in which I don't know over 90 of them have been of that form. And nobody has actually been in the consultation to see if shared decision making actually took place as a process. In the last Cochrane Review I think there were five or six randomized trials in which people were in the consultation to see if shared decision making took place.
The majority of those were actually conducted by our group, and we were able to demonstrate variable extent of shared decision making even when we had really cool and good-looking tools put in place to help with that process. So the first thing is shared decision making is a process that appears to be the result not only of the willingness of the participants and the ability and availability of tools to support them, but also has to do with the culture and expectations of the health system that is in place. And I haven't seen enough alignment of all those things to see if shared decision making in that context happens.
Second, I think adherence is an outcome that's very interesting, but most trials, as Brian Haynes demonstrated, most trials of adherence do not recruit people who are non-adherent at base line. So the opportunity to actually improve adherence when people do okay with adherence to their current regiment is very limited, and that has happened to us. Most of our trials, the adherence in the control group is over 90%. So it's very, very hard to actually make that better. And then finally, so what's the big deal if we cannot improve adherence or outcomes through adherence.
So that's a difficult question, and that's why our group continues to conduct research in this area to try to answer that question, but I think as a general rule if you want to care particularly for people with chronic conditions in which care has to make sense in their lives that there is no way for the clinicians, particularly now that clinicians don't live in the same communities as most of their patients, don't live the same lives as most of their patients, can't even relate to some of the complexities that some of our patients experience. Without those conversations to discover who the other person is, we may have a tough time getting the right treatment for the right person which is an essential component of quality.
And another factor particularly now in the context of significant clinician burn out, that without discovering who the person is that we're caring for, where do we get the meaning of our work? And I think as clinicians, particularly those of us who work with chronic patients, it is absolutely essential for our own wellbeing to discover that the work that we're doing in caring has a face, has a name, has a life. And it is helping people regain their health or at least helping them cope and thrive that not only are they better, but we also get our meaning.
We also get our energy. And we also get ourselves ready to see the next patient. >> Victor, I have thought previously that you have exceptional, probably unique insights into shared decision making. And I'm left at the end of the conversation reinforced with that impression. Is there any final comments or observations that you would like to share with us? >> Well, that's very kind of you, Gordon. My hope is that -- and my expectation is that shared decision making will probably go away as it refers to a single technique or something broader that I think we are currently describing as making care fit.
And this notion of making sure that care fits in the lives of people, not only in terms of their values and preferences, but also in their practical considerations of implementing treatments in complicated lives, is one of the ways in which medicine can be practiced well and can be made more effective. So in the process of making care fit sharing or co-creating those treatment plans with patients, making sure that they are minimally disruptive, and that the ones we pick from and that we bring forward are the ones that are supported by high quality evidence might help us improve the care that we give folks.
So making care fit becomes an important way of making evidence-based medicine continue to be an important contribution to the lives of people. >> Lovely additional perspective there, Victor. Thanks very much. It's been great having you join us. >> Thank you very much, Gordon, for this opportunity. And, as always, great chatting with you. [ Music ]
Segment:0 .
[ Music ] >> This is Gordon Guyatt. I am one of the Editors of the "User's Guide to the Medical Literature." And this morning I'm going to be talking to an author who's been very prominent in the "User's Guide to the Medical Literature" in a number of the chapters of the book, and the leader on one of the chapters that deals with shared decision making.
And that is Victor Montori who's a professor at the Mayo Clinic. Victor, welcome. >> Thank you, Gordon, a pleasure to be here. >> Let's jump right in then with the topic of shared decision making. And of course, we're interested in shared decision making in the context of evidence-based care. How does shared decision making advance evidence-based care? >> When one thinks about evidence-based care, one has to remember that there are several principles, of course one of which is that you make decisions on the basis of the body of evidence, that not all evidence is created equal and there's a hierarchy of evidence in terms of the confidence that one derives in the estimates of effect whether it's a harm or benefit.
But then it's evidence-based care. It's evidence-based medicine. And to care for people one has to make sure that the tests and treatments that one is going to use make sense intellectually, emotionally, and practically to the people we're trying to help. That's why in evidence-based medicine there is a principle that the evidence alone never tells you what to do, that you have to consider if one were to be standing from the clinician's perspective, one has to consider the context, the values, and preferences of the patient.
I deal mostly with patients with chronic conditions, and oftentimes they are in charge of enacting their own care, organizing it, and making it work in the context of their lives. And one could easily say the same thing from their perspective. As patients decide how they're going to care for themselves, they would want to incorporate the experience, expertise, and evidence that the clinician offers in the context of their lives and in the context of their own values, preferences, and goals. How might we achieve that? How do we get to find out what makes sense in the lives of people?
It is with their participation. It's with their involvement. And by considering and working through with them what aspect of their situation requires action, and then figuring out together what action does the situation require, a dance that we sometimes call shared decision making, we can ensure that not only are we using the best evidence, but the care that comes out of that and is decided upon makes sense in the life of people. >> Now many clinicians, maybe virtually all clinicians nowadays, provide care considering clinical practice guidelines to which they are exposed.
How do we square shared decision making with the clinical practice guidelines that are telling physicians how to manage their patients? >> Clinical practice guidelines often give strong recommendations. Unfortunately, sometimes too often. And strong recommendations sometimes have been described as just do it recommendations. Those I think work the best when they are mostly don't do this recommendations because in that situation it keeps patients safe.
For treatments that for most patients it would make sense to enact and to use them, to implement them, because they're most likely to do more good than harm, and there may be strong recommendations in favor of them, if the intervention requires patients to implement them in their lives say through adherence to therapy, then it is problematic to have a just do it recommendation without taking into account the conditions of living that patients have. And so even in strong recommendations and just do it recommendations in favor of interventions in which patients are responsible for the safe implementation of an intervention in their life it is very important to use shared decision making to make sure that for this patient the general recommendation applies, that in their context they can implement that, and to figure out if they need additional support to do it in a safe manner.
For other recommendations, further suggestions, or weaker conditional recommendations, there is a built-in room for consideration and discussion of specific circumstances of people. And among those circumstances, among the biological issues that clinicians may consider, there will be psychological and social issues and issues of preferences and goals that must be taken into account in configuring a treatment program for patients. So for most patients in the context of current guidelines, when those guidelines are well developed, strong recommendations in favor of interventions they have to implement in their lives, the implementation of those may require involving patients in making sure that they can safely do so.
And for conditional recommendations, it is essentially the best way to implement those recommendations to have those discussed with patients and work through together what are the issues and make sure that those recommendations, which are written for people like them, result in the right treatment for this person. >> Well, I'm wondering if there are situations when evidence-based care can happen without involving patients in decision making. For instance, are you seriously suggesting that a patient comes into emergency with a clear myocardial infarction, and you start a shared decision making exercise about whether they should receive aspirin or not?
>> Am I seriously suggesting that? Are you seriously asking that question? [ Laughter ] I think that -- I think that our primary job as health professionals is to take care of people. And the circumstance often dictates what is possible, is feasible, and what's desirable. I think as a general rule we do not do things to people without their authority or their authorization. That's the basis of informed consent. But when the situation opens up and the urgency allows and there is value beyond let's call it political correctness, when there's value in terms of determining what exactly fits better in this patient's circumstance, I favor that conversation.
Now we have to recognize, and this is not in the book because this I think has been worked out after the publication, that there are multiple purposes of shared decision making. The original version was about choosing. It was about opting between doing or not doing or between option A and option B. But there are other forms of shared decision making that are related to patients with chronic conditions, for instance, in which what is sorted out is not really what you want or what you prefer, but really what is the right solution to the problem the patient's facing at the moment.
So solving problems together sort of action in which we're making decisions. People who work in the hospital, for instance, do this all the time when they conduct their discharge planning rounds where nurses, family, and clinicians sort out when and with what arrangements patients are going to leave the hospital. And that is an exercise in shared decision making in which it's less about what you want, and what choices you make, but more about solving problems. And similarly, in the situation of a patient at the end of life when they are looking at writing their last chapters in their own books, oftentimes particularly folks with limited experience show up at the bedside and offer patients choice.
You know, would you like to do CPR or not? Would you like ventilation or not? And all of a sudden, the patient is faced with a menu of things that they can opt in and opt out. And that comes across as uncaring and formulaic and procedural when, in fact, what you want to do is care for those folks. There is a form of shared decision making in which you're sorting out these more transcendental issues with patients that have nothing to do with choosing or selecting and more to do with again trying to make sure that the last chapter in your life is written with the same ink as you've been writing the other chapters as you were living.
>> I work in hospitals and so I'm regularly sorting out at the time of admission a patient's code status. You suggested that if I just go in and address this directly perhaps in the way I'm doing that I'm at risk of coming across as uncaring. How should I be doing that? >> We've all seen people who are a little bit too rushed, a little bit trying to check the boxes and move on to other tasks, who may for the first time bring up the issue of death as a possible outcome of this hospital admission.
For this otherwise young person perhaps admitted with a severe [inaudible] or something of that nature. And all of a sudden somebody walks in, usually the least experienced member of the team, and is asking the patient about, "In the event that you die, what would you like to have happen?" And yes, that comes across I think often as very uncaring and again formulaic. There are multiple ways of handling this. I think, you know, one of the ways, for instance, our group has been dealing with these sorts of issues is to conduct research into how might we do shared decision making in different circumstances.
For instance, when elderly people get admitted from nursing homes into the emergency room because they have suffered a -- some deterioration, it is oftentimes those same people who may have expressed in a previous admission to hospital that they don't want to come back. So in the emergency room we have now tested a small tool that shows trajectories that patients may follow as they get admitted to hospital with problems when they're quite elderly. And so then that allows the emergency room doctor to talk to the patient about what is desirable in this trajectory.
Is it alleviation of the discomfort and return to the nursing home for further care? Is it alleviation of the discomfort and admission to the hospital to work through it? And so forth. And it's not in the answer that the care arises, but rather in discovering from the discussion of those things what matters to the patient, and in the clinician working through creatively with the patient to honor what seems to matter to them and what kind of care might work best for them. This is in contrast with the approach of we don't have beds, we have beds, we better send you back, do you want to be admitted, and you want people to intubate you and pound on your chest.
When we look at the videos of the discussions that people are having today you wouldn't use the word care necessarily to describe it. And I think it's unintended, but that's what it comes across. >> Have I got it right? It's having the conversations in a respectful and caring way that attends to the patient's needs at the time. Is that the basic message? >> It is a big part of it. I think not only just respectful, but I would add curious.
I think we sometimes because of urgencies and speed and other things, we don't give ourselves the opportunity to dig deeper into understanding the person in front of us. And I think this idea of uncovering or figuring out their values and preferences, it's really a bit of an adventure in understanding the person that is behind a diagnosis or behind the bed number in front of us. And it's in discovering that person that we work together to -- and again usually the right answer emerges from that discussion.
It becomes clear. And it requires respect, but it also requires curiosity and compassion and a real willingness to really help this person out. It is when we stop seeing individual people in front of us, and we start seeing a patient with AFib or a patient with MI or a patient with a diagnosis, and we start treating them as a member of a class that although standardization comes on, which is sometimes helpful to keep people safe, we lose then the opportunity to individualize care in a manner that is both scientific, it's evidence-based, and is also appropriate for who they are.
It's respectful of their situation. It's kind. >> Yeah. I've picked up from conversations before this caring element that is undoubtedly crucial, but I find it intriguing and interesting the element of curiosity about finding out who the person is. I really like that. I'm often after having the conversations with the patients documenting some aspects of their preferences on the chart. What are your thoughts about what after such conversations, about what should be put on the chart or what is necessary to put in the chart, and what may not be necessary?
>> That's a great question. So a couple of things about that. One is the chart today plays kind of a series of roles in care. In the United States where I work, the chart is mostly a documentation for billing sort of tool. And so most of my colleagues I think as a matter of reflex rarely read what's on the chart. There are however a lot of initiatives to document in the chart goals of care, priorities of care, values, preferences. And it seems to me that it is an exercise in extending this engineering approach to healthcare where if you just document this, then care will sort of adhere to it or be consistent with it.
I think the important part of documenting might be the eliciting and the important part of the eliciting might be that exercise in creating a moment of connection, of deep human connection, between the clinician and the patient. So the clinician gets a chance to know who they're caring for, and the patient gets a chance to develop a similar relationship that might help with trust and the old therapeutic alliance that sometimes is so important to help people recover. So I'm not obviously a big fan of documenting in sort of a checklist or in sort of a non-narrative way.
Oftentimes I also find it very hard to describe people's preferences once you pick them up, to describe them in simple terms. If that is possible, then of course it might be helpful to contribute to teamwork if other members of your team have the same awareness that you have with all the work that you've done in figuring out what makes sense and what matters to this person. But I would be quite concerned of initiatives that have as an outcome the documentation of preferences because I'm afraid what we will do is we'll make a system that consistently achieves a documentation and nobody will know who the patient that completed that form, that led to that documentation, truly is.
>> What about the tangible benefits of shared decision making? Improving adherence to treatment, lowering costs, improving health outcomes. What are the benefits of shared decision making in those aspects? And if there's not much evidence shared decision making does something in those areas, why the big deal? >> So I'll start with the bottom line, and the bottom line is that shared decision making has not been shown to consistently improve disease control, disease outcomes, treatment adherence for therapy, resource use, intensity or invasiveness of interventions, overall costs.
None of that stuff. Actually, there's not even a consistent finding in saying that shared decision making takes more time. First of all, why is it that we have no consistent evidence of these things? And if it cannot do any of that, then why the big deal? So I'll start by telling you that I think that there are multiple forms of shared decision making that most of the ones that have been tested are of the kind where patients are given information and then sent to the battleground of discussing with their clinician.
It's almost like a defensive action against the clinician who is going to offer surgery or is going to offer treatment. By preparing the patient for that conversation, the expectation is that the patient and the clinician will have a shared decision at the end. The best evidence suggests that when you educate or train the patient and then send them to have a discussion with the clinician, and the clinician knows that they've received that training, the clinician will verify that the patient understood the information by maybe asking a question, and then will ask the patient what they would like to do.
And so it becomes not a shared decision, but in fact it becomes what people call an informed decision which is when patients make the call and clinicians follow. The most likely scenario has been tested. There's been more than 100 randomized trials in which I don't know over 90 of them have been of that form. And nobody has actually been in the consultation to see if shared decision making actually took place as a process. In the last Cochrane Review I think there were five or six randomized trials in which people were in the consultation to see if shared decision making took place.
The majority of those were actually conducted by our group, and we were able to demonstrate variable extent of shared decision making even when we had really cool and good-looking tools put in place to help with that process. So the first thing is shared decision making is a process that appears to be the result not only of the willingness of the participants and the ability and availability of tools to support them, but also has to do with the culture and expectations of the health system that is in place. And I haven't seen enough alignment of all those things to see if shared decision making in that context happens.
Second, I think adherence is an outcome that's very interesting, but most trials, as Brian Haynes demonstrated, most trials of adherence do not recruit people who are non-adherent at base line. So the opportunity to actually improve adherence when people do okay with adherence to their current regiment is very limited, and that has happened to us. Most of our trials, the adherence in the control group is over 90%. So it's very, very hard to actually make that better. And then finally, so what's the big deal if we cannot improve adherence or outcomes through adherence.
So that's a difficult question, and that's why our group continues to conduct research in this area to try to answer that question, but I think as a general rule if you want to care particularly for people with chronic conditions in which care has to make sense in their lives that there is no way for the clinicians, particularly now that clinicians don't live in the same communities as most of their patients, don't live the same lives as most of their patients, can't even relate to some of the complexities that some of our patients experience. Without those conversations to discover who the other person is, we may have a tough time getting the right treatment for the right person which is an essential component of quality.
And another factor particularly now in the context of significant clinician burn out, that without discovering who the person is that we're caring for, where do we get the meaning of our work? And I think as clinicians, particularly those of us who work with chronic patients, it is absolutely essential for our own wellbeing to discover that the work that we're doing in caring has a face, has a name, has a life. And it is helping people regain their health or at least helping them cope and thrive that not only are they better, but we also get our meaning.
We also get our energy. And we also get ourselves ready to see the next patient. >> Victor, I have thought previously that you have exceptional, probably unique insights into shared decision making. And I'm left at the end of the conversation reinforced with that impression. Is there any final comments or observations that you would like to share with us? >> Well, that's very kind of you, Gordon. My hope is that -- and my expectation is that shared decision making will probably go away as it refers to a single technique or something broader that I think we are currently describing as making care fit.
And this notion of making sure that care fits in the lives of people, not only in terms of their values and preferences, but also in their practical considerations of implementing treatments in complicated lives, is one of the ways in which medicine can be practiced well and can be made more effective. So in the process of making care fit sharing or co-creating those treatment plans with patients, making sure that they are minimally disruptive, and that the ones we pick from and that we bring forward are the ones that are supported by high quality evidence might help us improve the care that we give folks.
So making care fit becomes an important way of making evidence-based medicine continue to be an important contribution to the lives of people. >> Lovely additional perspective there, Victor. Thanks very much. It's been great having you join us. >> Thank you very much, Gordon, for this opportunity. And, as always, great chatting with you. [ Music ]
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