The Physician’s Weekly #PWChat series continued with another thoughtful discussion on Wednesday, Sept. 6, which focused on the shared decision making process between doctors and their patients in the ED.
It was co-hosted by Marc Probst, MD, and Hemal Kanzaria, MD, and was inspired by their recent article Shared Decision Making in the ED. This TweetChat included the topics: why there are still misconceptions surrounding how and when to use shared decision making; necessary and sufficient factors for determining if a clinical scenario is appropriate for shared decision making; and much more!
You can view our upcoming schedule, or read our other #PWChat recaps here.
Below are the highlights from the chat. You can read the full transcript here.
Question 1
Q1: Why are there still misconceptions surrounding how & when to use #SharedDecisionMaking? What are some examples?#pwchat
— Physician’s Weekly (@physicianswkly) September 7, 2017
A1: Misconcept#1 SDM = informed consent. SDM is based on ethical construct. Informed consent is a legal construct. #PWChat
— Hemal Kanzaria (@hkanzaria) September 7, 2017
A1: Misconcept#2 Goal of SDM is to decrease resource use. Not true. Goal of SDM is patient-centered care.
— Hemal Kanzaria (@hkanzaria) September 7, 2017
A1: Misconcept#3 SDM shifts decision to pt. Rather, SDM invites collaborative decisionmaking to extent patient is comfortable. #PWChat
— Hemal Kanzaria (@hkanzaria) September 7, 2017
A1: I think the main misconception is that SDM is simply communicating well with patients. In fact, it’s much more than that. #PWChat
— Marc A. Probst (@probstMD) September 7, 2017
A1: Also, I hear clinicians say that they have “used” SDM to get a patient to follow some course of action…but that’s not correct. #PWChat
— Marc A. Probst (@probstMD) September 7, 2017
A1. A good example would be deciding between an aggressive vs. conservative treatment. #SharedDecisionMaking #pwchat https://t.co/pdaLu1rlaS
— Linda Girgis, MD (@DrLindaMD) September 7, 2017
Question 2
Q2: What factors are necessary & sufficient to determine if a clinical scenario is appropriate for #SharedDecisionMaking?#PWchat
— Physician’s Weekly (@physicianswkly) September 7, 2017
A2: 3 factors: clinical equipoise, decision-making ability, + enough time (both pt and MD). #PWChat
— Hemal Kanzaria (@hkanzaria) September 7, 2017
A2: I would add that clinical equipoise can include a lot: if two reasonable MDs might do two different things, SDM is appropriate #pwchat
— Elizabeth Schoenfeld (@emschoenfeld) September 7, 2017
A2: Agree. Equipoise basically means that there are 2 or more medically reasonable options. @hkanzaria #pwchat
— Marc A. Probst (@probstMD) September 7, 2017
Question 3
Q3: What does clinical equipoise refer to in ED context & how should it be factored into #SharedDecisionMaking?#PWChat
— Physician’s Weekly (@physicianswkly) September 7, 2017
A3: Some amount of clinical equipoise must be there for #SDM to be appropriate. Otherwise, MD should make a clinical recommendation #pwchat
— Marc A. Probst (@probstMD) September 7, 2017
A3: (1/3) Occurs when > 1 reasonable management option, each w relatively equal potential for harm or benefit. #PWChat
— Hemal Kanzaria (@hkanzaria) September 7, 2017
A3: (2/3) Each option may be favored pending pt values + preferences. #PWChat
— Hemal Kanzaria (@hkanzaria) September 7, 2017
A3: (3/3) Given same situation, 2 patients may voice preference for dif paths due to unique values. #PWChat
— Hemal Kanzaria (@hkanzaria) September 7, 2017
Question 4
Q4: What does compassionate persuasion refer to & how does it play into #SharedDecisionMaking?#PWChat
— Physician’s Weekly (@physicianswkly) September 7, 2017
A4: Compassionate persuasion is a benevolent attempt to persuade a pt to receive care that is consistent with their goals and values.#pwchat
— Marc A. Probst (@probstMD) September 7, 2017
Usually think about this when there is 1 clear best management approach, but patient is reluctant to pursue. #PWChat
— Hemal Kanzaria (@hkanzaria) September 7, 2017
MD should explore reasons for reluctance, and assess what options fit w/in pt’s values. #PWChat
— Hemal Kanzaria (@hkanzaria) September 7, 2017
Question 5
Q5: Why would a patient be unwilling and/or unable to participate in #SharedDecisionMaking?#PWChat
— Physician’s Weekly (@physicianswkly) September 7, 2017
A5: There are many reasons. All comes down to decision-making capacity. E.g. Intoxication, advance dementia, acute psychosis… #pwchat
— Marc A. Probst (@probstMD) September 7, 2017
A5: But a pt may also rather adopt a passive role in decision-making based on their cultural or social background. And that’s okay. #pwchat
— Marc A. Probst (@probstMD) September 7, 2017
I would add is that without enough information patients will generally defer to MD. More info + invitation will facilitate SDM #pwchat https://t.co/amup33X6v1
— Elizabeth Schoenfeld (@emschoenfeld) September 7, 2017
A5: Personal experience w my south asian grandparents…they preferred MD to decide bc of trust + expectation of altruism. #PWChat
— Hemal Kanzaria (@hkanzaria) September 7, 2017
Question 6
Q6: In what situations should #SharedDecisionMaking be forgone or delayed?#PWChat
— Physician’s Weekly (@physicianswkly) September 7, 2017
Q6: If there is truly no time to discuss options in an emergent situation, then clinical action should be initiated right away. #pwchat
— Marc A. Probst (@probstMD) September 7, 2017
A6: Such emergent situations are rare overall, but do occur in the emergency department. #pwchat
— Marc A. Probst (@probstMD) September 7, 2017
Question 7
Q7: How does #SharedDecisionMaking (SDM) in the ED differ from SDM in the primary care or other practice setting?#PWChat
— Physician’s Weekly (@physicianswkly) September 7, 2017
A7: In ED, less time for pt & MD to make decision. Seconds count. Pt may also have less ability to get input from family/friends. #PWChat
— Hemal Kanzaria (@hkanzaria) September 7, 2017
Q7 Oft not the same pressure/urgency/upset for #SharedDecisionMaking in Primary or other setting vs ED #pwchat
— kathy kastner (@KathyKastner) September 7, 2017
Uncertainty is high in ED and explaining uncertainty can be hard, and may increase stress to patients #pwchat https://t.co/UD7ghEsJPr
— Elizabeth Schoenfeld (@emschoenfeld) September 7, 2017
A7: Also, there is generally no chance to prepare for #SDM prior to the ED visit. Can do so in 1* care. #pwchat
— Marc A. Probst (@probstMD) September 7, 2017
Question 8
Q8: What’s “fast food medicine,” & why is it important to differentiate it from #SharedDecisionMaking?#PWChat
— Physician’s Weekly (@physicianswkly) September 7, 2017
A8: Fast food medicine is the “customer is always right” approach to medicine, whereby pts can order anything they want. Not SDM. #pwchat
— Marc A. Probst (@probstMD) September 7, 2017
A8: SDM isn’t ordering from menu. It is working together to help pt, accounting for their preferences & values. #PWChat
— Hemal Kanzaria (@hkanzaria) September 7, 2017
IMHO, the concept/practice of SDM should also be part of what ‘we patients’ learn: eg the questions to ask #pwchat
— kathy kastner (@KathyKastner) September 7, 2017
Question 9
Q9: Is the purpose of #SharedDecisionMaking to be medico-legally protective? Why/Why not?#PWChat
— Physician’s Weekly (@physicianswkly) September 7, 2017
A9: No…but that may be a result. Genuine pt engagement and collaboration may have addn benefit of less medicolegal risk. #PWChat
— Hemal Kanzaria (@hkanzaria) September 7, 2017
Q9: That is not the purpose. The purpose is genuine pt engagement. But it could be a desirable side effect. #pwchat
— Marc A. Probst (@probstMD) September 7, 2017
? For you A9- if you had a great SDM conversation and relationship, but bad outcome, who would you feel was responsible? #pwchat
— Elizabeth Schoenfeld (@emschoenfeld) September 7, 2017
Good (tough) question @emschoenfeld Maybe shared responsibility after shared decision? #pwchat
— Marc A. Probst (@probstMD) September 7, 2017
Question 10
Q10: What are the common barriers to #SharedDecisionMaking in the ED?#PWChat
— Physician’s Weekly (@physicianswkly) September 7, 2017
A10: Lack of time (both perceived and real). Lack of patient decision-making ability (e.g, dementia, intoxication etc.). #PWChat
— Hemal Kanzaria (@hkanzaria) September 7, 2017
Q10: Time-pressure is an oft stated barrier. Linguistic barriers are also common. #pwchat
— Marc A. Probst (@probstMD) September 7, 2017
