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April 19, 2019

Shared Decision Making and the Importance of Time

Author Affiliations
  • 1Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
  • 2Knowledge and Evaluation Research Unit, Mayo Clinic, and The Patient Revolution, Rochester, Minnesota
JAMA. 2019;322(1):25-26. doi:10.1001/jama.2019.3785

Uncertain evidence and the uniqueness of a patient’s health care issues often make it difficult to identify the best course of care. These instances are becoming increasingly common as more people live longer with multiple chronic conditions and care becomes more complicated. Clinical decisions may involve screening or treatment with new toxic drugs in older patients; timely use of adjuvant, palliative, or pain care; or prioritizing care at the end of life. Shared decision making is essential in the care of patients in these complicated situations. For clinicians, being able to and choosing to spend time on understanding what truly matters to patients when making decisions together is an achievement that makes the work of clinicians meaningful and rewarding.1 Yet many clinicians have insufficient time to engage in shared decision making.

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    5 Comments for this article
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    The secret of the care of the patient is in caring for the patient
    John Clark, MD | Alaska Native Medical Center
    I agree wholeheartedly with the content of this article. These sentiments were most eloquently expressed by Francis Peabody in the landmark article "The Care of the Patient" published in JAMA March 19,1927 (1). In the concluding paragraph Peabody writes: "The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient".

    Technological advances, specialty care, and remarkable advances in pharmacologic treatment of many diseases have made our patients lives better. These advances have come, however, with both a very high monetary as well as time cost. "Time, sympathy, and understanding" are fundamental and requisite components in achieving our goal of alleviating suffering and improving health. Because these aspects of care are difficult to measure and to document (how do you document a silent pause?) they have been inappropriately discounted in our current system. We need to rededicate ourselves to putting patients first, even if this means sacrificing "efficiency", production, RVU's and profits.

    REFERENCES

    1. Peabody, FW. The Care of the Patient. JAMA. 1927;88(12):877-882. doi:10.1001/jama.1927.02680380001001
    CONFLICT OF INTEREST: None Reported
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    DPC to the rescue!
    Dan Di Iorio, M.D. | Integrated Care - sole proprietor, family physician, primary care sports medicine
    "Necessity is the mother of all invention" (Plato). The remarkable expansion of Direct Primary Care is an undeniable consequence of both patient and physician dissatisfaction with the evolution of primary care practice. Depersonalization of care rendered by the gradual contortion of evidence-based medicine to satisfy burgeoning bureaucracies has eroded the trust once conferred upon physicians by individuals and our society. The DPC model provides an affordable, accessible and personalized ecosystem where we can once again assure patients that we are here to listen, advise and serve their best interests. In DPC we reclaim time for the betterment of patient care.
    CONFLICT OF INTEREST: None Reported
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    The Risk/Reward Challenge
    Jock Hoffman | CRICO/Risk Management Foundation of the Harvard Medical Institutions
    I've worked in the medical error/patient safety aspect of health care for 30+ years and this may be the most coherent description of the shared decision making dilemma I've come across. There is no set sequence, or block of time, or order of give-and-take that can be prescribed for all patients. Some patients having to make life-altering health care decisions can do so with no hesitation and while texting their co-workers about missing tomorrow's meeting. Other patients, no matter how much time and how many family members are helping will never quite grasp the gestalt of their options. And there is no test to assure patients and caregivers that all parties fully comprehend the situation and future actions. On top of that, clinicians have to worry about the patient in the waiting room who, if he or she has an adverse outcome, will recall getting short-changed because the patient ahead of them took up too much time.

    I don't mean to imply it's hopeless, just complicated and often frustrating. But a sincere effort and a truly shared (and documented) exchange do set a foundation against an allegation of indifference or negligence, and establish the opening to finding the right way for that patient during that encounter.
    CONFLICT OF INTEREST: None Reported
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    Change the Way Clinicians Think
    Bob Flora | Houston, Texas
    The biggest roadblock to shared decision making is the unwillingness of clinicians to give up the "I know what is best for you " attitude. Patients are often given options based on the clinician's biases, risk tolerance, preferences, and values, which do not coincide with what the patient wants.

    Then, time is definitely against you. Too often the patient is presented with a decision to make without having had the time or opportunity to consider and reflect upon it as well as an opportunity to seek out additional information. With respect to the latter, patients are terribly
    handicapped as 75% of the literature clinicians rely upon is not in the open literature, and the best a patient can get is an abstract.

    Lastly, cost is almost never considered by the clinician, nor discussed with the patient. Costs are more than monetary. There is the time lost to pursue various procedures as well as the effects of the procedures, assessments, and therapies.

    Only once a patient is fully informed, is given an opportunity to add his or her own potential alternatives to the process, and is given time seek additional information and to reflect and deliberate, will we have shared decision making. In the absence of this, it is merely paternalism disguised as informed consent.
    CONFLICT OF INTEREST: None Reported
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    View from the Other Side of the Stethoscope
    Wendy Harpham, MD, FACP | Presbyterian Hospital Dallas; University of Texas at Dallas
    As a physician-(cancer) patient, I believe we can overcome the barrier of time constraints. I applaud all efforts that support "develop[ing] policies that allocate meaningful time for care."

    My experiences on both sides of the stethoscope led me to see such policies as one of many vital steps needed to narrow the gap between what we know of ideal care and the care patients receive.

    "By finding creative time savers for clinicians and promoting a culture that values the time needed for high-quality care, we can continue to help patients benefit from both the miracles of
    modern medicine and the art—the heart—of medicine." (1)

    We can...we must.

    References

    1. Harpham, Wendy S. Time Savers. Oncology Times. doi: 10.1097/01.COT.0000437981.56682.4d (https://tinyurl.com/wshot111013)
    CONFLICT OF INTEREST: None Reported
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