Shared Decision Making
Lately I have been thinking and reading about decision making at the personal, group, and organizational level. (Yes, I know that is weird subject matter for a physician.) The reason for my interest is my perception that dealing with the challenges of the next five years requires that we develop a common understanding of how we ought to make decisions for the best interests of our patients. Now as a physician, I clearly think having medical knowledge and skill are important, but as an old physician, I note that the way we make decisions has changed significantly over time. Let me start our consideration by making some observations.
When I started medical school in 1970, physicians saw patients, made decisions based upon their personal expertise supplemented in some cases by diagnostic radiographs and selected lab tests. The topic of the day, consistent with the theme of the second half of the 1960’s was the notion that medical paternalism was as bad as any other sort of “expert” knowledge, and physicians were admonished to create partnerships with their patients. I have not heard a serious discussion of this notion in a long time, and it is my perception that those of you who graduated in the past 20 years can’t imagine just telling your patients what to do and expecting them to actually do it.
Somewhere along the way, and I can’t quite say precisely when I became aware of it, the notion of independent decision making by physicians (and their patients) began to be challenged. Mostly the challenge was fueled by concerns about money and the fact that patients generally do not have to deal with the financial consequences of the decisions they make in conjunction with their physicians, and physicians are compensated more for doing that not doing tests, procedures, visits, etc. Clearly, the current CMS “core measures” process represents a deliberate attempt to force physicians to follow pathways defined by experts divorced from the care of individual patients and puts the burden of proof on the physician who thinks the pathway is inappropriate for a particular patient.
Of course, CMS does not specify all aspects of quality care, but it does require us, as the organized medical staff, to ensure that quality care is delivered. As I have said before, there are lots of areas where medical knowledge is incomplete, and now we can even have dueling guidelines, but it is clear that the expectation is that we use a consensus definition of quality. Today, we are not very far down this road, but our ongoing peer review process, as well as our various departmental quality assurance activities makes this both urgent and imperative. I challenge each of you to take time from your practices to sit down with other members of your department to define consensus definitions of high quality care. I must also warn you that opting out of the process, because you are “too busy” means that you are surrendering your right to object when the department reviews your cases. In terms of decision making at the group level, physicians believe in broad-based, vigorous discussions of options, which can be both messy and time-consuming. However, I think such a process is consistent with our “freedom” as individual practitioners. The weakness, though, it that physicians also tend to be conflict-avoidant and sometimes even passive-aggressive, so when a consensus is reached that is not unanimous, there can be a tendency to simply put off closure of the issue. Reaching consensus is not the same as reaching unanimous consent. Once the discussion has taken as long as it takes to explore it completely and the vote has been taken, as an organized staff we must resist the desire of individuals or small groups to do a “pocket veto.” Said another way, we need to reach closure on some of these issues, and soon.
The last way of looking at decision making is at the organizational level. For way too long, physicians and hospital staff have operated in parallel with communication being informal between individual physicians and individual staff, or at the level of senior staff with the Medical Executive Committee. In my view, we do not have a robust system that affords ample opportunity for everyone to get involved in the decision making process as it affects day to day care. I believe this is a major impediment to quality of care, whether defined by us or by our patients. One of the issues is a distinct difference in how physician groups and management groups reach decisions. I have outlined what I think to be a fair characterization of the usual physician process. To paraphrase Winston Churchill, we are often two people divided by a common language.
I encourage you to think about this issue of how we decide, and how we share decision making in your department and committee meetings. We will certainly look at it from the Medical Executive Committee and Quality Council perspectives, and hopefully even at the Board of Trust level. The decisions we make on this in the next few months are going to determine our effectiveness in meeting the challenges of the next few years. If you are too busy to think about it now, you may have more time than you either want or need to think about it in the future.
Written 18 March 2011, revised 4 May 2014.
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