Ep 173: Shared decision-making - what it is, and what it isn't, with Diane Slater

[00:00:00] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality

[00:00:09] research to quality practice.

[00:00:12] I'm Clara Dern, the editor-in-chief of the Journal of Orthopedic and Sports Physical

[00:00:16] Therapy.

[00:00:17] It's great to have you listening today.

[00:00:23] Share decision making Many of us think we're practicing it, but

[00:00:27] if we take a detailed look at our practice, we might realise that we're not quite there

[00:00:32] yet.

[00:00:33] Today, Diane Slater, physiotherapist and educator is going to help us self-diagnose our

[00:00:39] shared decision making practice and help us identify what shared decision making in

[00:00:44] musculoskeletal rehabilitation practice is.

[00:00:48] And what it isn't.

[00:00:50] Diane is a musculoskeletal physiotherapist with a research interest in and passion for

[00:00:55] delivering high quality person-centered care.

[00:00:59] She's had a varied clinical career ranging from working in the UK's National Health Service

[00:01:04] to working in elite sport.

[00:01:07] Diane's currently based at our World University in Denmark where she's working with clinicians

[00:01:11] and international collaborators to develop a person-centered care education programme for physiotherapists.

[00:01:19] Diane's also a coach and mentor to clinicians and non-clinical practitioners supporting them

[00:01:25] to bring person-centered care to their work.

[00:01:29] Diane Slater, welcome to JOSPT Insights.

[00:01:31] Hi Claire, thank you for having me and thank you for the invitation.

[00:01:36] It's a pleasure to have you on the podcast and you've moved into mentoring and a clinical

[00:01:41] education role in musculoskeletal rehabilitation which is one of the many reasons why I'm so

[00:01:46] thrilled to have you join us on JOSPT Insights today because we're talking about honing

[00:01:52] our interpersonal skills that are so crucial to setting up a positive clinical encounter

[00:01:58] with patients.

[00:01:59] As one of my colleagues says, it's all about how do you demonstrate to a patient that

[00:02:04] you are trustworthy?

[00:02:06] Today we're focusing specifically on the decision-making part of that clinical encounter.

[00:02:11] Tell me about how you were first taught to make clinical decisions in practice and then

[00:02:17] let's have a chat about how you approach to sharing those decisions has evolved as your

[00:02:23] clinical experience has evolved.

[00:02:25] I actually don't think I was taught, like if I look back in my education, I really don't

[00:02:32] think we had any specific education.

[00:02:34] So my method has probably been trial and error and that's how I've worked my way through

[00:02:41] and understood from when I've made mistakes and realized oh you can't do it that way,

[00:02:46] I need to do a different way and so it has certainly been an evolution that's certainly

[00:02:51] evolved over the many years.

[00:02:54] And I don't even know whether there was a time where I realized oh, I need to be more intentional

[00:03:01] or more specific in what I'm doing and I think it was just as I started to learn more about

[00:03:07] the importance of the therapeutic relationship around person centered care that I've then

[00:03:12] dived into the theory.

[00:03:14] So it's probably been quite late on in my career and I'm still learning.

[00:03:21] I think that's going to really resonate with a lot of people listening today, it certainly

[00:03:24] resonates with me when I reflect on my education as a physio.

[00:03:29] We didn't really talk about the decision-making part of it and sharing that decision with patients.

[00:03:36] It certainly came through on clinical placement but I don't ever remember truly learning

[00:03:40] the theory as you say.

[00:03:42] So let's get into the specifics of shared decision-making which is what we're talking about

[00:03:46] today and I want to make sure that we're all on the same page with what we understand

[00:03:51] shared decision-making is so can you put a straight what is shared decision-making Diane?

[00:03:58] It's actually interesting because many people will give you a different answer to that question,

[00:04:03] there's not sort of worn widely accepted definition but I think it can be helpful if we

[00:04:07] think of three principles.

[00:04:10] So to think of shared decision-making as a process rather than an outcome, that it's collaborative

[00:04:17] so you're working with people and that it is evidence based on that evidence based discussion

[00:04:24] or deliberation includes looking at risks and benefits.

[00:04:30] We're all on that page of understanding informed consent and people making an informed decision.

[00:04:36] So I think what we're talking about with shared decision-making is going just a bit further

[00:04:41] beyond the informed decision and bringing the person into some of that decision-making.

[00:04:46] Does that seem like a fair way to characterize it to you?

[00:04:49] It does and I think it's really important to delineate between informed consent and shared

[00:04:53] decision-making so the income of home consent might be the outcome of a shared decision-making

[00:04:59] process but what we're talking about is how we got there, the journey that we got there

[00:05:04] before the decision was made.

[00:05:08] Before we get to the process and exactly how it works in practice, let's talk about why

[00:05:13] you might want to embrace shared decision-making in clinical practice.

[00:05:17] What are some of the key benefits of shared decision-making?

[00:05:22] There's really an ethical imperative to do shared decision-making.

[00:05:25] There's a phrase that comes from the King's Funds work in the UK.

[00:05:30] This phrase is no decision about me without me.

[00:05:33] I think if we were all able to put ourselves in the shoes of a patient and think, would

[00:05:40] we want a decision to be made without us if it's to do with our care?

[00:05:45] Morally ethically it's the right thing to do.

[00:05:49] That's sort of the main reason.

[00:05:51] There are of course other benefits that have been shown in research and so you could think

[00:05:58] about the fact that more informed patients actually make different decisions and those

[00:06:04] decisions, if they're more informed, they usually tend to reduce low value care.

[00:06:12] That they can reduce the decision or conflict or decision or regret which is just really

[00:06:18] about people's challenge in making a decision or how much they might regret having made

[00:06:24] a certain decision.

[00:06:26] With that comes problems related to complaints and litigation.

[00:06:31] If you've had a shared decision-making process, it should be the opportunity to save money

[00:06:36] and to save time because there should be less complaints, there should be less litigation.

[00:06:41] There's also maybe not so much in musculoskeletal physiotherapy but in other areas of healthcare,

[00:06:47] there's quite a lot of research showing that there's higher patient satisfaction as

[00:06:50] well as higher clinician satisfaction.

[00:06:53] There's also that could be some better outcomes.

[00:06:58] As I say, there's probably a need for more research to show that health outcomes are improving

[00:07:05] in relation to the shared decision-making process but certainly patient report and experience

[00:07:10] measures have been shown to improve when you have a shared decision-making process.

[00:07:16] I've heard a lot of people say that shared decision-making takes a lot of time and time

[00:07:22] is a key barrier.

[00:07:24] What are the main barriers to shared decision-making and are they even truly barriers?

[00:07:32] Time certainly comes up nearly every opportunity when shared decision-making is spoken about

[00:07:37] and to be fair, it is an actual barrier.

[00:07:41] I think of grouping barriers in three groups.

[00:07:44] You have the barriers that are reported by clinicians which are accurate and an increase

[00:07:50] length of time would be one of those.

[00:07:52] I think we have some indication that it can take, let's say, between five and seven

[00:07:57] percent longer in a consultation to use shared decision-making process but that's an opposed

[00:08:01] to using a paternalistic approach.

[00:08:04] There's also then these barriers that are reported by clinicians that maybe are not accurate.

[00:08:09] Clinicians often say our patients don't want to be involved in decision-making and unfortunately

[00:08:15] we're not very good at identifying which patients do you want to be involved in which

[00:08:19] ones don't.

[00:08:20] That's sometimes maybe it's not accurate.

[00:08:23] There are some barriers that are not reported or recognized by clinicians that we see

[00:08:27] more from implementation studies and this can be literally a two cognitive bias and attitudes

[00:08:34] actually of the clinicians.

[00:08:35] It's really common that clinicians think they are already doing shared decision-making

[00:08:41] and unfortunately when they're observed or when they're, you know, when they dive

[00:08:45] a little bit deeper perhaps they're not and so at that stage that's a bigger barrier

[00:08:51] and I think that's why you know after a couple of decades worth of work into shared decision-making

[00:08:56] we're still having problems and it's still a challenge but not unsamountable challenges.

[00:09:02] What does shared decision-making when it's done well look like?

[00:09:06] What does it sound like?

[00:09:08] What do people do and then maybe we can contrast that with a couple of examples of where

[00:09:13] people might think they're doing shared decision-making and it really isn't.

[00:09:19] So shared decision-making which is of high quality will be a situation where the person

[00:09:26] knows the decision needs to be made so as a clinician you're inviting the person that

[00:09:31] you're working with to make that decision and that's quite clear and that might involve

[00:09:35] a team of people not particularly in sport, it might not just be a one-on-one but it also

[00:09:39] could include family and care as well.

[00:09:42] So you'll be this recognized moment of where everyone's aware that decision needs to be made.

[00:09:49] Then the next but I think which is kind of what it which is obvious from the outside

[00:09:54] is that there's this deliberation, this collaborative deliberation process and it's about

[00:10:00] sharing knowledge and sharing preferences and it's bidirectional or multi-directional if

[00:10:06] the small than two people in the team and so you would see that people are working very much

[00:10:11] together, it's not negotiation, it's not persuasion and then everyone's working towards making a

[00:10:19] decision but this doesn't necessarily mean that the decision at the end is made either by the patient

[00:10:25] or it's even a consensus but there's the journey to get there that I think is the most recognizable

[00:10:32] thing. And what are some of the clinical scenarios that where you would have used or where you do

[00:10:38] use shared decision making in practice Diane? It's really come from this idea of clinical

[00:10:45] equipals and that is a situation where there are perhaps a number of options and there's not one

[00:10:52] option that's more superior than the other options and that could be where there's just the evidence

[00:10:58] basically says that treatment A is no better than treatment B but it also could be a situation where

[00:11:05] we don't have really good enough evidence to say whether A or B is better and so there's a lack of

[00:11:10] certainty and it's those situations where you really want to be using shared decision making

[00:11:16] because there are limits to to share decision making and its use that perhaps there are many

[00:11:23] situations and including in physiotherapy where shared decision making is maybe not appropriate

[00:11:29] or certainly maybe it's not the starting point. Can you share a couple of those concrete examples Diane?

[00:11:35] So often what happens is you have people having this idea about shared decision making that all

[00:11:40] the patients come in demanding a treatment and actually that means I just have to do what

[00:11:45] the patient wants and we have to be really clear that shared decision making it's not consumerism,

[00:11:52] it's not about just letting go of the evidence, it's not about just bowing down to what the patient

[00:11:58] patient prefers and so let's say let's say as an example a patient comes in and requests

[00:12:05] let's say therapeutic ultrasound for a chronic low back pain. In that situation as a clinician

[00:12:12] we do have a professional responsibility and so this could be a case where shared decision making

[00:12:17] is limited, it could be limited by ethical reasons, by professional reasons but also maybe even

[00:12:22] societal reasons as well. So if I've got a situation where someone is asking for the therapeutic ultrasound

[00:12:30] where it's not recommended and we know like from the most recent WHO guidelines are on chronic

[00:12:35] low back pain that it's something that we it's not recommended for treatment. Now I'm not going to

[00:12:41] enter into a shared decision making process with this person and at that stage you could say well

[00:12:47] actually maybe respectful negotiation or compassionate persuasion is appropriate but I'm

[00:12:53] maybe going to take some principles of shared decision making in the person centeredness of it

[00:12:59] while some having that conversation. So I'm still going to be really curious about what their

[00:13:03] beliefs are, I'm still going to be really interested to know why they feel so strongly about having

[00:13:09] that particular treatment option, I'm not going to dismiss it and it might be that actually

[00:13:15] discourse back to this idea that more informed patients make different decisions,

[00:13:19] that if we sit and have a conversation that perhaps it becomes a shared decision making process

[00:13:25] when we start to talk about the other options that are available.

[00:13:29] One of the other things I hear quite often from clinicians is they'll say well

[00:13:34] the patient asked me what would I do if I was in their shoes? How do you approach that if someone

[00:13:39] says to you will Diane what would you do if you were me? Certainly a common scenario and

[00:13:44] you know understandable because it can be quite overwhelming for patients to make these decisions

[00:13:49] and we don't want to abandon them to make those decisions alone. What good way of well what I think

[00:13:56] is a good way of responding to that is it's easy to highlight well I'm not you so the first thing

[00:14:04] for us to consider is that what might be right for me might not be right for you but I am really

[00:14:11] interested in working with you to and to help you understand the risks and the benefits.

[00:14:18] The other thing as well is people might still really want that kind of expertise and that

[00:14:23] the expert opinion and so there is a way of delivering advice but in a way of leaving it open

[00:14:29] on the table so you can say something like well I can tell you what I've seen many patients do or

[00:14:36] I can tell you you know of my experience in this scenario but let's also try to bring it back to

[00:14:42] like what are your preferences, what are your priorities and also like how comfortable are you

[00:14:47] with certain risks and then you're able to still survive support because providing support is

[00:14:54] really important in this process and they are looking for that reassurance perhaps in the decision

[00:15:01] making process and so you're joining them you're not abandon them to make the decision by themselves

[00:15:06] let me throw another clinical scenario at you that's a bit closer to my my clinical comfort

[00:15:13] someone has an ACL injury and they're trying to decide whether to have a reconstruction or not

[00:15:18] how would you approach that there's a bit more clinical equiapoise in that scenario I think so how

[00:15:23] would you start to approach that decision with an athlete or a patient. The really important

[00:15:28] place for me to start is for me to be aware of what my bias is in that particular situation

[00:15:35] because we're going to bring that to the conversation and this is where we might end up

[00:15:39] persuading without realizing so I want to have that in my mind and keep myself in check with

[00:15:47] that. I'm going to explain to the person that there is a decision to be made and an explain

[00:15:52] actually maybe it's a surprise for them but that there is more of this clinical equiapoise than perhaps

[00:15:57] they would expect and having access to some data can be helpful but I'm always going to be asking

[00:16:04] again I'm going to be asking do they want to see the data because some people want to see

[00:16:07] this and people don't but showing them that there is this choice then sort of the next phase is

[00:16:14] to me to really be able to understand their preferences so I think you could do it in a few different

[00:16:22] ways you could sit down and ask them like you know have you got any good instincts like what are

[00:16:26] your feelings and you're really just trying to help them verbalize these ideas and then you say okay

[00:16:33] and would it be useful if we look at some of the information that we have available to us in

[00:16:38] evidence and then depending on their response you need to walk people through this information

[00:16:45] giving them plenty of opportunity to ask questions but also giving people opportunity

[00:16:51] if they need more time that they might want to go away they might want to discuss it with someone

[00:16:55] else they might want to discuss it with a coach they might have certain timelines that they

[00:16:59] have in their mind that they want to get back to maybe there's a competition that's the main focus

[00:17:04] that might be their pinnacle of their career so there's so much context specific information

[00:17:11] that you just need to create space for people to be able to bring that into the decision-making process

[00:17:17] how do you feel about decision aids for this kind of discussion Diane?

[00:17:23] decision aids can be really useful and we have plenty of evidence to show that they can help

[00:17:28] improve people's knowledge and understanding and that they can reduce decisional regret.

[00:17:34] The problem with decision aids by themselves is that they won't work as a standalone

[00:17:40] that's not shared decision-making just living to give someone a decision aid to go off and

[00:17:43] to don't just give them the leaflet exactly and that just happened and actually in quite a lot

[00:17:49] of implementations that's been happening where people are doing it before an encounter after an

[00:17:53] encounter. The great thing about decision aids if they've been developed in line with international

[00:18:00] standards for decision aids because there's many that have not been and if they have up to date

[00:18:05] information which unfortunately some of the like some of the hard copies won't be up to date so let's

[00:18:10] say you've got a reliable decision aid that's been well developed in line with the international standards

[00:18:16] actually the way that this worded it might help to the wording might be in a way that is

[00:18:22] more appropriate for the person's health literacy level. It might help to remove some of your bias

[00:18:28] as well. It also can be a really useful thing for people to show to other members of the decision

[00:18:36] making team and it helps you to keep the communication stable. How do you decide whether

[00:18:43] a decision aid is a good one or one to disregard? For me, it's also looking like appa development

[00:18:50] process. So I want to know when it was published, when it was created, I want to know what resources

[00:18:58] were included in that and I also need to kind of bear in mind like depth of the evidence that

[00:19:04] it's based on and also keeping in mind the population that that evidence is in relation to

[00:19:11] and how well that relates to the person who's sitting in front of me. So you do need to put a little

[00:19:16] bit of work in in choosing your decision aids and unfortunately I think that there are maybe

[00:19:23] a smaller number that are of high quality but I think that's improving and I think the more

[00:19:29] that we can use digital technology and AI, that I think that will increase and we'll get more

[00:19:35] reliable decision aids. Knowing what the reasonable options are when you're supporting someone to

[00:19:41] make a decision in a shared decision making process is clearly part of the keys to this whole

[00:19:46] process succeeding. I think it can feel really daunting though to try to keep on top of all of

[00:19:52] the research and all of the information that's coming out, new guidelines are coming out all

[00:19:57] of the time, guidelines are coming out from different organisations. What are some of your tips

[00:20:02] for folks listening to us today about how they can try to keep a handle on options and reasonable

[00:20:11] and what sort of information to go to or to put in the filing system however people choose to

[00:20:18] organise information? I think it is a concern when we start to talk about a shared decision making

[00:20:23] like people feel overwhelmed like how am I going to keep on top of it all. I think the first thing

[00:20:28] is to remember is no one's expecting you to keep it all in your head, it's not realistic,

[00:20:32] it's not possible so I think that's the first thing is give yourself permission to think that

[00:20:38] I don't know this and actually give yourself permission to tell your patient that you don't have

[00:20:42] all the answers as well at the moment. If we're evidence-based practitioners which most of us will

[00:20:48] strive to be, we should have a plan anyway whether it's related to shared decision making or not,

[00:20:56] we should have a plan as to how we're keeping up with this like the most recent guidelines or

[00:21:02] evidence and there's a couple of ways of doing something. First of all ask yourself have you got a plan

[00:21:08] second you could think about let's say is the evidence likely to change? On this particular topic how

[00:21:18] stable is it? So we talk about background knowledge and foreground knowledge. So the background

[00:21:22] knowledge is just like the anatomy and maybe even some of the pathology stuff that doesn't change

[00:21:26] but some of it we know is likely to change but can you create a routine and it might not be very

[00:21:34] much time, you might not have much time, it could be a couple of hours even in a year that you do

[00:21:38] this but you that you have identified certain resources that you know are reliable. More likely to be

[00:21:45] I'd say institution-based rather than guru-based and then you could have some dedicated time that

[00:21:53] you have to that you could work with your colleagues as well so that you're not trying to do it all

[00:21:58] all by yourself and the other thing is that you can set up like email alert so you can follow certain

[00:22:05] institutions on like on social media so that as the most important things are coming through

[00:22:11] you are aware of them. You just you know I think for me I need to have my filter set really quite

[00:22:18] clearly so because otherwise you'll end up with a really long list of papers to reading, you're not

[00:22:23] going to get around to reading them anyway but having the plan in the first place I think is the key

[00:22:30] and I think that's also where as you say some trusted sources are really helpful and often

[00:22:37] places that are putting together trusted guidelines because that's really a place where you're

[00:22:41] pulling a lot of information whether it's a platform like up-to-date or dynamed that some

[00:22:47] folks will have access to through their through a large health network whether it's the nice

[00:22:52] guidelines if you're working in the UK whether it's the clinical practice guidelines that we publish

[00:22:57] at JOSPT there's a lot of those sorts of evidence synthesis pieces that are much more accessible

[00:23:04] and I think organisations are aware that there's a lot more work that needs to go into making those

[00:23:09] big documents easier to read and digestible and translatable so people are putting together

[00:23:16] things like patient summaries or plain language summaries or infographics that summarise exercise

[00:23:22] programmes there's a lot more work I'm seeing that is really trying to support clinicians

[00:23:28] to do the best work and to support patients. Let's start to wrap up our chat now Diane

[00:23:35] I'm really keen for us to hear your top tips for how people can embrace even more in their

[00:23:43] clinical practice these principles of shared decision making. Following on from the conversation

[00:23:48] about the plan maybe that's you know one-stop in point is just just check your plan around how

[00:23:53] you're going to keep up to date with the evidence but there are like there are a few tips that I can

[00:23:58] give you just the things that have worked for other people they might not all work for you but let's

[00:24:03] see if the inspire you to maybe try something so it seems important for people to know where they

[00:24:10] are currently at in their practice so that could be having some kind of reflective practice or doing

[00:24:18] some observation with some colleagues if you're feeling brave I would strongly encourage people to

[00:24:23] consider making a video recording of some patient encounters because that bias about is strong

[00:24:29] and it's very difficult for us to be able to kind of go past that so having some kind of reflection

[00:24:35] then just drawing your attention to decision making in general when are the decisions being made what

[00:24:42] decisions are being made are they suitable for shared decision making just start to connect with

[00:24:47] how decisions showing up in your practice and who you're involving start into something small

[00:24:54] trying to set your own goal and like thinking about this has been small steps towards

[00:24:59] being more consistent with shared decision making. I'd also encourage you to have a chat with some

[00:25:04] of your colleagues or your team member and just have it some company in your journey like have

[00:25:10] a colleague who can give you some support because this is a journey and it's probably worth thinking

[00:25:15] about it as an investment in the future and having third person to help you to reflect I think

[00:25:23] can be really helpful. Diane thanks for getting us going on this journey of rediscovering our

[00:25:31] clinical practice reassessing how we're going in decision making and sharing those wonderful tips on

[00:25:37] how we can do a bit of self-diagnosis I think on our shared decision making practice. It's been such a

[00:25:42] pleasure having you join me on the podcast today. Diane Slater thanks for joining me on JOSPT insights.

[00:25:49] Thank you Claire it's been a pleasure.

[00:25:56] Thanks for listening to this episode of JOSPT Insights. For more discussion of the issues in

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