1. Promoting Shared Decision Making Jack Fowler Informed Medical Decisions Foundation

2. Shared decision making means 1. Patients are told about all reasonable options 2. Patients are told about pros and cons of options 3. Patients share goals, concerns and preferences with providers

3. 4 Reasons Not to Increase Efforts to Do Shared Decision Making 1. We already do it 2. Patients don’t want it 3. Patients can’t understand 4. Doctors should make decisions

4. We already do it?

5. National Survey of Medical Decisions Cancer screening tests: – Colorectal Cancer – Breast Cancer (mammography) – Prostate Cancer (PSA testing) Prescription medication decisions: – Hypertension – High Cholesterol – Depression Surgical interventions: – Knee/hip replacement – Cataracts – Lower back pain

6. Mean Proportion of Knowledge Items Answered Correctly Medication Initiation: Cancer screening: Elective surgery:

7. Discussion of Pros and Cons- “some” OR “A lot” Medication Initiation: Screened for Cancer: Underwent surgery:

8. Did HCP Offer an Opinion and Ask for Patient’s Own Opinion? Medication Initiation: Screened for Cancer: Underwent surgery:

9. PATIENTS DON’T WANT IT?

10. Testing our First 30- Minute BPH Program How would you rate the amount of information?

11. One Universal Truth Every time we ask, people (particularly physicians) underestimate how much patients value getting information about their medical conditions and being involved in decisions.

12. At Dartmouth-Hitchcock Patients routinely see decision aids for at least 11 different decisions They are surveyed after they see them

13. Who Should Make Decisions? Dartmouth patient data collected between July 2005 and July 2009

14. Would You Recommend DA for Others Dartmouth patient data collected between July 2005 and July 2009

15. Patients can’t understand?

16. Findings with Respect to Literacy Compared understanding of risk reduction for samples of college students and senior citizens recruited from community centers Both groups were stratified by score on a numeracy test

17. Percent of Respondents Who Understood Risk Reduction by Numeracy Level and Quality of Data Presentation

19. Doctors should make decisions?

20. Top Three Goals and Concerns for Breast Cancer/Herniated Disc Decisions Condition: GoalPatientProviderp Surgery: Keep your breast? Chemotherapy: Live as long as possible? Reconstruction: Look natural without clothes Reconstruction: Avoid using prosthesis 7% 59% P<0.01 33% 71% 96% 80% 0% 33% P=0.01 P=0.05 P<0.01

21. We are not doing it now

22. Patients do want it But many perceive their doctors do not welcome questions and patient participation in decision making

23. Patients can absorb complex information However, it has to be presented well

24. Decisions should not be delegated to physicians Because most medical decisions involve trade offs and quality of life issues Providers will not know what patients care about unless they ask At the moment, they do not routinely ask

25. SO THAT IS WHY WE ALL NEED TO WORK TO PROMOTE THE IDEA THAT PATIENTS ROUTINELY SHOULD BE INFORMED ABOUT THEIR OPTIONS AND THEIR PROS AND CONS HAVE A VOICE IN MEDICAL DECISIONS

26. THANK YOU.