Effectively engaging patients in everyday health-care decisions

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Applied Evidence

Effectively engaging patients in everyday health-care decisions

J Fam Pract. 2017 October;66(10):E1-E6

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References

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Pictographs reveal that there is a values-sensitive decision to be made and visually demonstrate the outcomes associated with each option. Both pictographs and bar graphs have been shown to improve patient understanding and satisfaction.¹¹ The benefit of pictographs is their ability to effectively, and simultaneously, convey both the numerator and the denominator in frequency statistics.^12,18

There is high-quality evidence demonstrating that decision aids enhance an individual’s knowledge about the treatment and screening options available to them. A 2014 Cochrane review of the effects of decision aids found that they increased average knowledge scores when compared to usual care.¹⁵ Decision aids also improved accurate perception of risk.¹⁵ It is our belief that one of the reasons pictographs work so well is that they combine the salience of absolute risks with and without intervention.^12,13

Beyond increased understanding, the Cochrane review also found high-quality evidence indicating that people who make decisions using decision aids feel less decisional conflict when compared to usual care.¹⁵ Moreover, in the context of SDM, decisional conflict may contribute to patients passing the decision-making responsibility to their clinician.¹⁹ And finally, there is moderate-quality evidence that patients are more likely to participate in decision-making when given tools such as pictographs.¹⁵

A potential barrier to putting pictographs into practice concerns perceptions that decision aids increase the length of office visits. Indeed, previous studies have identified perceived time constraints as one of the major barriers to enacting SDM in clinical settings.²⁰ On this topic, the Cochrane review offers variable yet potentially promising results: Studies of the effects on appointment length ranged from a decrease of 8 minutes to an increase of 23 minutes.¹⁵ These results suggest that, under the right circumstances, pictographs can be used to facilitate SDM within the constraints of current clinical practice. More research is needed to determine the optimal circumstances that promote efficient SDM.

2. Elicit the patient’s unique values and priorities

Formalized approaches to building rapport with patients have been popular for more than 2 decades,^21,22 and they are now routinely part of medical training. Nevertheless, there is always room for improvement when it comes to aligning treatment and screening recommendations with patient values. Some decision aids are designed to offer the added benefit of clarifying individual values and, thus, increase the likelihood that patients will make decisions that are more in line with their goals.¹⁵

There is evidence that decision aids, such as pictographs, enhance patients' knowledge about the treatment and screening options available to them.

When decision aids are not available to elicit patient values, clinicians can integrate preference-clarifying questions as part of the standard patient encounter.²³ These questions are aimed at surfacing the values underlying what the patient wants, what the patient does not want, and most importantly, why.

“Why” matters because it ultimately helps the clinician understand the patient’s mindset, enabling the clinician to help the patient make choices that serve his or her values.²⁴ Eliciting values not only promotes patient well-being and self-determination, but also facilitates the development of empathic patient-clinician partnerships.

Categorizing decisions. Regardless of the particular method chosen to elicit patient values, the underlying questions faced by many patients often fit into one of 2 categories: 1) Do I prefer quality of life over length of life? or 2) Am I willing to be inconvenienced now to prevent more severe illness later? Clarifying the category into which a decision falls may open the conversation and help to explore patients’ values and priorities. Alternatively, asking questions such as, “Thinking about this decision, what is the most important aspect for you to consider?”²⁵ may facilitate the conversation.

Much of the research on techniques geared to elicit values comes from the palliative care and oncology literature.²⁶ Although this research generally focuses on decisions about serious illness or end-of-life preferences, preference-sensitive decisions in primary care settings create a need for clinicians who are effective in eliciting patient values.

The more serious and preference-sensitive the decision, the deeper the clinician needs to explore the patient’s personal goals. Despite scant literature about seemingly innocuous decisions, we recommend that clinicians elicit from their patients a brief, but overt, acknowledgement of the values guiding their choice for most preference-sensitive decisions.

3. Offer a professional recommendation

Once clinicians have a sense of an individual’s values and priorities, they are positioned to make a professional recommendation that aligns with these values and priorities, and leaves room for the patient to reach a decision. Historically, one of the clinician’s major roles was to provide advice and recommendations to patients. For a long time, this was done without the patient’s involvement in the decision-making.²⁷

With an increasing emphasis on patient self-determination over the last 50 years, there has been some concern that the pendulum is swinging too far in the opposite direction, with clinicians shying away from providing specific recommendations.²⁸ Although this line of thinking acknowledges the power of the clinician to influence patients, it falls short of distinguishing between a personal recommendation and a professional one. While personal recommendations have no place in medical decision-making, clinicians should offer patients a professional recommendation, along with their rationale.