In a discussion about how to engage patients, Mayo Clinic Professor of Medicine Victor Montori begins by clarifying the why. “I’m a clinician; I take care of people with diabetes. It’s becoming increasingly clear that the answer to almost any why in health care is because of high-value health care,” he says. “That seems to be the answer to anything and to everything.”
The problem is that high-value health care is a business school invention devoid of the traditions of medicine and medical practice, explains Montori. It makes sense as an accomplishment of the health system on the population, and when looking at the world from the C-suite “down into the factory floor where clinicians-turned-providers have to work with patients to produce this high-value care [and where] the patients, as employees of the system, are trying to accomplish this.”
But this idea that clinicians must engage patients because patients have to do the work that we need them to do so that we can produce value is problematic. Montori illustrates this with an example: One of his patients came in for her regular checkup. She had type 1 diabetes, had just turned 40, and had received a postcard from her primary care doctor telling her to get a mammogram. She wasn’t sure if joining the mammography screening program was a good idea.
Montori used a shared decision-making tool to help her understand her level of risk and the pros and cons of joining the program versus delaying or not participating at all, and she decided to delay. Three months later, when she returned for another appointment, Montori noticed mammography results in her medical record. She told him, “I let my primary care doc know that I was not going to participate and then he pointed out that that would affect his numbers, so I did it for him.”
“I don’t buy that why as an explanation as to why we should work with patients to achieve patient goals,” says Montori. “We have to do it to advance their goals of care and we need to be careful that we don’t get that corrupted by the constant effort to try to get us to improve the value of health care.”
Moving on to how clinicians can engage with patients to help them advance their goals, Montori suggests carefully understanding what the patient’s situation is at the moment. “Not only the problematic situation from a health standpoint, but the problematic human situation in which, of course, chronic care and chronic disease take place,” he says.
“Understanding the patient’s problematic situation in high definition then leads to understanding what aspect of that situation demands action. Not all the problems need to be solved right away,” explains Montori. And then patient and clinician can discuss alternatives in response to the patient’s situation.
“Oftentimes, considering those alternatives allows us to clarify the situation in the first place, and vice versa, in an iterative process that continues until the patient and the clinician arrive at a solution as to a way forward that makes sense,” says Montori.
The solution needs to make sense not only intellectually and emotionally, but also practically, because one of the challenges in any behavior change is the implementation. “The patients will have to work to make this happen in their lives and if the plan does not make sense practically at this point within their situation, it’s just not going to happen,” he says.
“Many times, people talk about shared decision-making as presenting options, but without spending enough time on the situation we may get this very wrong,” adds Montori. He recalls a patient referred to him for uncontrolled type 2 diabetes and to start insulin. As they talked, it became clear that when the problem started a few months back, the patient’s daughter had told him she was going to marry a man twice her age, someone who’d been previously married and had two teenaged kids. The patient did not like his daughter’s fiancé or her decision to marry him, and the situation was gnawing at him. He didn’t want to ruin his relationship with his daughter or compromise his own principles. Rather than verbalizing this, his blood pressure rose, he gained weight, and his blood sugars rose.
What is the situation of this patient that demands action? The father-daughter relationship? His high blood sugars? Do we respond to it with counseling and support or with insulin? “Getting the situation right will allow us to find what is the solution that actually makes sense in that particular situation,” says Montori.
“In the context of high-value health care, some people have taken shared decision-making to be something else, a strategy perhaps to get patients to do what we need them to do so that we can get our numbers,” says Montori. “Well, that’s not it, is it?” Others may think shared decision-making is distributing information to patients, as if they lack information, or offering choices, “as if it was choice deficiency syndrome that made them sick.”
We give patients information and choice to identify the best course forward. But it’s not about distributing information and choice so that patients will have to make those decisions by themselves. “This not only transfers the work of agonizing about what’s right but also transfers the responsibility of it quite conveniently,” says Montori. “It is also not a strategy to improve value.” If you look at 105 randomized trials of interventions to promote shared decision-making, it’s difficult to find impact on outcomes, adherence, safety, utilization, or cost.
“We need to be very careful when we promote or identify shared decision-making as a strategy to promote a different behavior in our patients, to advance their health situation, that we do it for the right reason,” says Montori. “We make sure that we don’t give insulin to the person who’s agonizing about their situation of their daughter.”
How might we create the environment or the situation to use shared decision-making successfully? The first thing to realize is that we can’t use it as a tool for industrial health care. “This is a deeply personal approach in which patients and clinicians can identify together what we need to do.”
We need to create the space and time and bring the technology that enables conversations without much friction. “When in a hurry, when pressed for time we default to treatment for patients like this instead of defaulting or identifying what is the right treatment for this patient,” says Montori. “Clinicians will have to be retooled and retrained, not just to check the boxes and get everything right, but to begin to see their patients in high definition.”
For patients, receiving health care shouldn’t be a hurried-up way of making sure the doctor gets their numbers, but they should be seen as themselves, not just another someone with diabetes, for example.
“We have to rekindle the idea that when they come in they’ll be seen. That they will receive care. That they will actually get their problems addressed or at least listened to and solved to some extent. That we in health care will be in a position to be engaged by them, by the boss, in advancing health and their health goals as defined by them.”
From the NEJM Catalyst event Patient Behavior Change: Building Blocks for Success, held at Duke University, April 4, 2018.