EXECUTIVE SUMMARY

Shared decision-making in surgery can lead to better informed consent and improved communication between clinicians and patients.

  • Its value is in picking out the information the patient needs and discussing this in every conversation.
  • The patient’s lifestyle and priorities play an important role in making a decision under this model.
  • Learn about shared decision-making through literature reviews, then practice various scenarios.

When surgeons begin shared decision-making with patients, it can be an eye-opening experience that improves patient-surgeon trust and communication, according to the authors of a study.1

“I am comfortable in characterizing shared decision-making as the ultimate informed consent,” says Robert A. Probe, MD, FAAOS, orthopedic surgeon at Baylor Scott & White Health in Temple, TX.

Surgeons tend to favor shared decision-making in cases where uncertainty exists over treatment options, but as something that is optimal for every surgical decision.2

An observational study of patients with orthopedic conditions revealed patients reported higher satisfaction and experienced better health outcomes when they were well informed through shared decision-making. They also made decisions that aligned with their individual preferences.3

Informed consent and going over the risks and benefits are rarely handled well. However, through shared decision-making, it is thorough and leaves patients empowered. “The value of shared decision-making is picking out what information the patient needs and talking about it in every conversation,” Probe says. “I think the biggest epiphany for me is that I thought I was doing good informed consent and appreciating patients’ values. Probably 99% of physicians would say they’re doing fine.”

But after practicing some scenarios of shared decision-making, Probe realized it was different from the patient conversations he had adopted in his practice. “The difference is it focuses on the whole process,” he explains. “All the different models for shared decision-making are extending invitations to the patient.”

The usual practice is the surgeon decides for the patient, based on his or her knowledge and experience. With shared decision-making, the patient’s knowledge and experience in lifestyle and circumstances are a big part of the process.

Instead of telling patients what the right answer is, surgeons would make time to listen to the patient and say, “I’m very interested in your perspective. This is not a decision for me, but this is a decision for us.”

To start, read about how shared decision-making works in literature and practice various patient-surgeon scenarios. “As I got into it, became involved, and looked at the literature, I became a convert,” Probe says.

Probe’s paper shows models of shared decision-making, including the three-talk model, the SHARE model, the Informed Medical Decisions Foundation (IMDF) model, and the alteration to three-talk model.1

The IMDF model includes six steps: invite the patient to participate, present options, provide information on benefits and risks, assist the patient in evaluating options based on the patient’s goals and concerns, and assist with implementation.

Surgeons need to build some trust to help draw out the patient’s thoughts and concerns as they begin the shared decision-making process. “It’s a new [process] for many patients,” Probe notes.

Patients are accustomed to physicians telling them the decision, followed by a cursory nod to other treatment options. With shared decision-making, the surgeon would use different words: “There are reasonable ways to approach this problem. Here is one of the reasonable ways.” The surgeon would describe the risks and benefits, pros and cons, of each approach. Some patients will jump into the conversation at that point, asking questions or explaining more about what they expect from a surgery or treatment. Other patients will remain introverted, and the surgeon will need to break the ice.

“It’s always amazing to me that I can give my patients the same spiel, but they’ll have different understandings of it,” Probe says. “They react differently. With their input, I can gauge where they are.”

For example, one patient’s priority might be not to go through a long recovery period. The patient’s message in the shared decision-making conversation could be to ask for the procedure that is most likely to make him or her better in two months.

Another person may want a procedure that provides the best chance of keeping the patient healthy and mobile for long enough to attend a loved one’s wedding.

These patients are asking questions about the same medical issue, but their goals in finding a solution are different. Their clinicians need to find them the answer that is best for their priorities and circumstances.

Surgeons often will make decisions for patients without knowing all the patient’s personal information and goals. But patients also make the same mistake of deciding on a procedure based on their online research rather than waiting to learn the most accurate information and assessment from their physician.

“The patient will come into your office, saying he needs a knee replacement,” Probe explains. “Then, you talk with the patient, go through everything, and find out that this is not what he needs.”

The teach-back communication approach can help with the shared decision-making process. The Agency for Healthcare Research and Quality offers a chart with 10 elements of shared decision-making and the patient teach-back component.4 This is a sample of the chart’s shared decision-making elements and their definitions:

  • Role. Establish the patient’s preferred role in the decision-making process, including the patient’s choice of making the decision independently, defer to the physician, or decide collaboratively.
  • Alternatives. Physicians can discuss the medically appropriate alternatives and treatment options, which are the basis for a decision that is sensitive to the patient’s preference.
  • Uncertainty. Physicians should discuss the likelihood of treatments succeeding or failing. Base these observations on objective research evidence.
  • Preference. Elicit the patient’s preferred course of action, which is based on his or her expressed values and preferences, including how they would like to move forward or whether they would do nothing.

Surgeons can learn more about shared decision-making by practicing with various scenarios. These scenarios provide multiple choices for what a surgeon would say in a decision-making situation. The answer the scenarios identify as the correct one often is different than expected.

Probe found that after engaging in six scenarios, he still had more to learn about shared decision-making. But when he finally used the skills with a patient, the conversation was much more vibrant and productive.

“When there’s shared responsibility in decision-making, then patients’ go into it with their eyes wide open,” Probe says. “If patients have ownership in the decision, they’re much less likely to be critical of the decision.”

Following this problem can prevent problems while boosting patient satisfaction. For those interested in pursuing shared decision-making, a good adoption technique is to designate a champion in the organization.

Probe’s paper demonstrated the benefits of the process in orthopedic surgery.1 A chart solicits patients’ input on surgery for an Achilles tendon rupture. The chart informs patients they may want to play a role in their surgery decision. There are six action items: gather the facts, compare options, consider the patient’s feelings, decide, quiz, and summarize the decision.

Probe’s work also included a graphic that exhibits the reasons to choose surgery to repair a ruptured Achilles tendon and reasons to choose just wearing a cast or brace. Each rationale is presented with its opposite, such as, “I don’t want to risk another tendon rupture” or “I’m willing to take the risk of another tendon rupture if it means not choosing surgery.”

Patients can mark where they are on those decisions and see whether the surgery option is closer to what they want than the non-surgical option. “Surgeons who take the time to appreciate what the potential is for shared decision-making will naturally change how they communicate with patients,” Probe says.

REFERENCES

  1. Wilson CD, Probe RA. Shared decision-making in orthopaedic surgery. J Am Acad Orthop Surg 2020; Sep 11. doi: 10.5435/JAAOS-D-20-00556. [Online ahead of print].
  2. Kannan S, Seo J, Riggs KR, et al. Surgeons’ views on shared decision-making. J Patient Cent Res Rev 2020;7:8-18.
  3. Sepucha KR, Atlas SJ, Chang Y, et al. Informed, patient-centered decisions associated with better health outcomes in orthopedics: Prospective cohort study. Med Decis Making 2018;38:1018-1026.
  4. Battles J, Azam I, Reback K, et al., eds. Implementing Shared Decision-Making: Barriers and Solutions — An Orthopedic Case Study. Agency for Healthcare Research and Quality; August 2017.