How do we level the playing field for patients and clinicians to enable shared decision-making? Social psychologist Kathryn Pollak asks two experts in shared decision-making, Angela Fagerlin and Victor Montori, for concrete examples.
Many times, the situation is emergent and leaves little room to prepare, says Fagerlin. Yet preparation is crucial for improved shared decision-making and should be worked in wherever possible.
Fagerlin describes how a former colleague would give prostate cancer diagnoses over the phone. When she learned about this practice, Fagerlin initially thought it unethical. But over time, she saw its value. Calls were scheduled in advance so that patients weren’t caught off-guard, and the person calling had done the biopsy.
“They had a relationship with the doctor, it wasn’t an MA calling, and they were prepared for the call,” she explains. “They got to think about it. They got to do the reading and talk to their friends. So when they went to see their doctor for the first time [they were ready to make a decision].”
“If we wait until that appointment to get people prepared, it’s probably not going to work because they’re not going to ask questions or have preferences,” she says.
Montori suggests leveling the playing field in a physical way — where clinicians position themselves when talking to patients. “Recognize that for the clinician this could be a routine, and for the patient it will be a shock and it’ll be a new thing,” he says. “The clinician has to do the heavy lifting of that balancing of the power. Sometimes people talk about how patients have to come in empowered and ready. It’s just very unfair to demand that from people, and I think it’s better to demand that from the clinician,” he says.
He describes one approach that works for him: sitting on the floor.
“I’m a diabetes doctor. I examine feet a lot, and so I usually have some important parts of the conversation when I’m [on the floor],” he explains. “It really puts the patient in a much different position and perhaps a better position to have this [conversation].”
Avoiding jargon is another way to level the playing field. “When pressured by time, we’ll go back to our shorthand, and our shorthand involves a lot of jargon. And jargon is one of the subtle ways in which we establish our power,” Montori says. “Being mindful of that and creating spaces where we don’t feel rushed so that we don’t fall back into our shorthand, that may help.”
From the NEJM Catalyst event Patient Behavior Change: Building Blocks for Success, held at Duke University, April 4, 2018.