Decisions!

Webster defines decision as “a choice that you make about something after thinking about it: the result of deciding.”

In healthcare, we should be so lucky to have clear language around terms that are driving clinical care today! Patient engagement and shared decision-making are two terms that are used repeatedly but rarely with a description of what the terms mean or the related expectations for improving outcomes. But we are allocating time and resources to initiatives with these labels and expecting care delivery to be transformed.

Decisions in Care

Sometimes decisions are fun. Facing the yummy selections of homemade gelatos and ice cream at your local deli is a decision filled with anticipation for enjoyment.

Other decisions are not fun. Should I have a PSA test? Will the hip replacement be the answer to my pain and lead to riding my bike again? Then there are the very big decisions surrounding end of life.

Decisions about care for ourselves or for a loved one are not fun, and they require a thoughtful approach for both the patient and clinician. Today we refer to this process as shared decision-making. The origin of this concept is in the early days of evidence-based medicine when Sackett defined a process that is central to engaging patients with key information. According to the Cochrane Community,

“Evidence-based medicine is the conscientious, explicit and judicious use of current best clinical evidence from research.”

And Sackett contends that “it is the integration of best research evidence with clinical expertise and patient values.”

These words provide a powerful core to “patient engagement” if our cultures of care, our work environments, can adapt. But change does not come easily to care delivery. There are significant disruptive forces at play today that are further complicating the ability of clinicians and patients to speak to one another and to listen effectively.

In a Forest but Not Seeing the Trees

As an industry, we are unclear about the intent and the meaning of the terms patient engagement and shared decision-making. Given the variability in perception of the meaning of these terms, we risk time and resources embarking on projects aimed to “engage” and “share decisions” with patients. The external forces to demonstrate improvements in care by applying these concepts are increasing confusion for patients, families, and clinicians.

When one organization shows improvement based on application of its varied perceptions how can another organization replicate it? If the industry sees patient engagement as a “blockbuster drug” for healthcare’s ills but there is no clarity around the term, are we setting ourselves up for failure?

Much of industry sees patient engagement as the effective use of technology. As a long-time clinician, this concerns me because it further diminishes the value of the human beings who need our care.

Technology is a tool to aid communication, gather and synthesize key data, and aid transmission of a patient’s clinical data directly to his or her provider. But it is NOT the core of patient engagement, and it certainly is not the heart of shared decision-making.

A Compass to Guide Us Out of the Forest

Fortunately, a recent issue of Critical Care Medicine offers clarity and a framework for what it means to offer shared decision making in ICUs.

“Shared decision making is a collaborative process that allows patients, or their surrogates, and clinicians to make healthcare decisions together, taking into account the best scientific evidence available, as well as the patient’s values, goals, and preferences.”

The authors make a number of recommendations from a practice and ethical basis and one resonates with common sense: “Clinicians should be trained in communication skills.”

Why do we expect communication that includes active listening, good eye contact, and reflective statements for clarification to come naturally? If only quality communication were an inborn trait, there would be much less strife in our lives!