SHARED DECISION MAKING – WHAT IT IS AND WHY IT MATTERS

“Nothing about me without me”…. Picker Institute

Every day as a busy clinician you make countless decisions regarding patient care. This includes decisions about diagnostic options, treatments, dispositions of patients, follow up and management of your patients.  Some decisions have clear and compelling evidence, and few alternative paths. For example, a fractured hip needs to be repaired or acute bacterial meningitis needs antibiotics.  Therapeutic action supersedes rigorous patient discussion (but does not completely replace it). However, for many medical decisions, the evidence is not compelling or there are multiple similar options. In this case, truly patient centered care asks for thorough discussion and consideration of patient’s preferences and values in making the decision. For instance, which option to choose for early stage breast cancer has quite different effect on the patient’s appearance, survival potential, and cost? This is what is called by the Dartmouth Atlas, “preference sensitive care”. In these cases, engagement with the patient in making the decision in order to fully understand and take into account their preferences and values is of paramount importance. A Cochrane Review of shared decision making found that in 86 trials that were examined, there was a consistent improvement in patient knowledge, more accurate risk perceptions, greater number of decisions that were consistent with the patient’s values, reduced level of internal decisional conflict, and fewer patients remaining undecided or passive.

The Agency for Healthcare Research and Quality (AHRQ) has developed an approach to assist physicians and other caregivers in taking a systematic approach to Shared Decision Making. This approach called SHARE 1 provides a five step process that includes:

 

Step 1: Seek your patient’s participation. Communicate that a choice exists and invite your patient to be involved in decisions

Step 2: Help your patient explore and compare treatment options. Discuss the benefits and harms of each option

Step 3: Assess your patient’s values and preferences. Ask open and non-judgmental questions.

Step 4: Reach a decision with your patient. Decide on best option and arrange follow up

Step 5: Evaluate your patient’s decision. Revisit the decision and monitor its implementation.

 

AHRQ provides shared decision making tools for both clinicians and for patients.  These include:

 

 

 

 

Beside AHRQ, a number of other organizations offer patient decision aids for shared decision making which include:

A full inventory of resources of patient decision aids is available at:

https://decisionaid.ohri.ca/AZinvent.php

 

In coming blogs, we will dive more deeply into the steps outlined above, and explore communication with patients and overcoming health literacy barriers, and heightening cultural awareness in your practice.

Partnership HealthPlan of California is eager to assist network practices and clinicians at becoming more skillful in shared decision making, and will be offering onsite training. Stay tuned!

 

(www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/index.html

Submitted by Scott Endsley MD, Associate Medical Director, Quality

Trauma Informed Care – What You Can Do In Your Practice

PHC has had intensive care management programs in many of our FQHCs since 2012.  These care management programs will be evolving into our health homes programs in 2017.  Health Homes is an evolution of the patient centered medical home with an increased focus on substance abuse, integration of mental and behavioral health with medical care and a more intense effort to work with homeless members.

One of the new components in patient assessments will be a look at how trauma has affected the lives of our patients.  How serious is this problem?  Here are a few statistics:

  • Over half of women (55 to 99%) in substance abuse treatment report trauma
  • Nearly all women in the public mental health system (85 to 95%) have had trauma
  • Nearly all homeless veterans suffer PTSD
  • Trauma exposed youth have arrest rates 8 times that of same age peers
  • The economic costs of untreated trauma-related alcohol and drug abuse are estimated to have been $161 billion in 2000.

The Substance Abuse and Mental Health Services Administration (SAMHSA) concept of the trauma informed approach defines a trauma informed system of care:

  • Realize the widespread impact of trauma and understand paths to recovery
  • Recognize the signs and symptoms of trauma
  • Respond by integrating policies and procedures in your practices
  • Resist re-traumatizing patients

The goal is recognizing the effects of trauma on our patients is to provide an emotionally and physically safe environment for our patients.

How can you know if trauma is playing in a role in your patient’s behavior or choices?  You might start by asking about his or her childhood or how things are going at home.  Once you get a feel for whether trauma has affected your patient you may be able to be more direct in your questioning. The Life Events Checklist has 17 specific traumatic events, but you can consider a shorter list that we will be implementing into our PHC health risk assessments.

Have you been involved in or exposed to:

  • A natural disaster such as a flood, fire or earthquake?
  • Combat or a warzone?
  • Physical or emotional abuse?
  • Sexual abuse or assault?
  • Sudden violent death or unexpected death in someone close to you?
  • Any serious harm, injury or death caused by you?

Trauma is treatable. There are many evidence-based models and practices to help heal our patients and improve the behavioral manifestations of trauma.  A history of trauma is often hidden or denied and we don’t often ask about trauma in our patients with problematic behaviors.

How will this play out in your practices?  The next time someone acts out in your practice, consider asking “Can you tell me what happened to you?” instead of “What’s wrong with you?” You may be surprised at the answer.

And Now for Something Completely Different….

While most people associate “magic mushrooms” and “X” with illicit drug use some recent research indicates these substances may have a role with some of the most difficult-to-treat psychiatric patients.

Two studies published in the December edition of the Journal of Psychopharmacology used psilocybin and similar study designs to treat cancer patient’s depression and anxiety. Previous studies have (unsurprisingly) shown high rates of both conditions in cancer patients with life-threatening diagnoses along with difficulty in adequately treating these same conditions leading to a variety of poor outcomes. (e.g. decreased survival rates, increase in suicides, decreased function, among others)

Utilizing a crossover study and high or moderate dose of psilocybin versus placebo or very low dose psilocybin both studies found not only a marked improvement in both depression and anxiety scores but also improving measureable factors such as spiritual wellbeing, general life satisfaction, and quality of life, life meaning, and optimism, while decreasing cancer-related demoralization and hopelessness, and death anxiety. Even more remarkable the effect on depression and anxiety (with reduction rates as high as 80%) persisted for 6-8 months with only a single dose of psilocybin!!  Both studies even used a Mystical Experience Questionnaire (MEQ30) which “is a self-report questionnaire that evaluates discrete mystical experiences induced by serotoninergic psychedelics and is sensitive to detecting psilocybin-induced mystical experiences.” As an additional benefit, no subjects in either study suffered from any serious side effects.

 

Along this same vein the FDA announced this week that based on the success of small drug trials it is allowing large-scale Phase 3 clinical trials to study the use of MDMA, or Ecstasy, for patients with severe PTSD. The Multidisciplinary Association for Psychedelic Studies (MAPS), a non-profit group that advocates for the medical use of banned drugs, sponsored six Phase 2 studies that led to the FDA’s decision.

In 2 of the trials they studied combat veterans, sexual assault victims, firefighters and police officers that suffered from PTSD and had not responded to previous treatments. The average duration of symptoms was 17 years! Subjects were given 3 doses of MDMA a few weeks apart under supervision of a psychiatrist along with psychotherapy. This was also a crossover study.

One study showed a 56% decline in severity and by the study conclusion 2/3 no longer met the criteria for PTSD. In addition improvements persisted for over a year. The researchers have applied for “breakthrough therapy status” with the FDA which could allow approval by 2021. Other researchers urge caution, using the opioid crisis as an example of how the drug could be abused.

As a historical aside, MDMA was first patented in 1914 but in 1978 it was resynthesized by chemist Dr. Alexander Shulgin. (Dr. Shulgin was my toxicology professor during my MPH studies at UC Berkeley – an interesting man to say the least!) He gave it to friends in the psychiatric field to use for augmenting psychotherapy but when it spread to more general recreational use the FDA classified it a Schedule 1 drug and initial research was halted.

The results so far are promising but likely a long way off for routine clinical use.