Dealing with the Lack of Time for Detailed Shared Decision-making in Primary Care: Everyday Shared Decision-making

Abstract

Policymakers and researchers are strongly encouraging clinicians to support patient autonomy through shared decision-making (SDM). In setting policies for clinical care, decision-makers need to understand that current models of SDM have tended to focus on major decisions (e.g., surgeries and chemotherapy) and focused less on everyday primary care decisions. Most decisions in primary care are substantive everyday decisions: intermediate-stakes decisions that occur dozens of times every day, yet are non-trivial for patients, such as whether routine mammography should start at age 40, 45, or 50. Expectations that busy clinicians use current models of SDM (here referred to as “detailed” SDM) for these decisions can feel overwhelming to clinicians. Evidence indicates that detailed SDM is simply not realistic for most of these decisions and without a feasible alternative, clinicians usually default to a decision-making approach with little to no personalization. We propose, for discussion and refinement, a compromise approach to personalizing these decisions (everyday SDM). Everyday SDM is based on a feasible process for supporting patient autonomy that also allows clinicians to continue being respectful health advocates for their patients. We propose that alternatives to detailed SDM are needed to make progress toward more patient-centered care.

Electronic supplementary material

The online version of this article (10.1007/s11606-020-06043-2) contains supplementary material, which is available to authorized users.

“So much time and so little to do. Wait a minute. Strike that. Reverse it.” [Willy Wonka]

In recent discussions about the slow uptake of shared decision-making (SDM), one controversy has been the extent to which time is a barrier (see Box 1 for key elements that characterize SDM). Clinicians consistently emphasize that time is the most important barrier to implementing SDM.^1–3 Many SDM advocates remain skeptical, citing that better SDM does not, in fact, appreciably increase visit length.^{4, 5} Some even maintain that lack of time for SDM is a myth.^{5, 6} Although we agree that any change in practice can summon a perceived “lack of time” that has more to do with priorities than insufficient time, we insist that time-constraints are quite real in the primary care context.^{7, 8} Moreover, even though some desire a low threshold for advocating for detailed SDM, it is undeniable that detailed SDM for all substantive medical decisions in primary care is not realistic.^9–12

Box 1 Elements that characterize shared decision-making (SDM)⁴⁴

•Physician and patient both actively share information •The physician actively explores the patient’s values and preferences •The physician assists the patient in selecting the best option through supportive conversation •The physician is guided by the patient’s preferences both in how much information to share and how much to involve the patient in the decision process •The physician ultimately respects the patient’s right to make the decision

For non-major decisions in primary care, PCPs typically have just 1–2 min for SDM.⁸ Finding that visit lengths do not change much with vs. without SDM is not, in fact, reassuring. Primary care providers (PCPs) are adept at juggling multiple issues while keeping visit length constant.⁸ Spending more time on SDM for one topic can be compensated for by shortening time for other topics. As a result, asking PCPs to add detailed SDM (i.e., any form of SDM that averages more than 2–3 min to complete) will typically crowd out other care.

Thus, it is urgent that we consider alternative approaches to delivering more patient-centered care in different clinical contexts. In this perspective, we first review the strong evidentiary base indicating a need, in the primary care context, for an SDM approach that takes less time than current more detailed SDM models. Then, we offer for discussion and refinement a compromise proposal (everyday SDM) for PCPs who value the goals of SDM but find they are not engaging in SDM because of limited time.

THE NEED FOR BREVITY IN PRIMARY CARE

Because of the nature and volume of decisions in primary care, the argument for brief SDM is particularly strong. Early SDM models were developed in the context of high-stakes decisions like major surgery or starting chemotherapy.^{13, 14} However, most decisions in primary care are not high-stakes like a decision about major surgery. Yet, neither are they trivial. Consider screening for cancers (breast, prostate, cervical, colon, lung, ovarian, etc.): great examples of the type of substantive, intermediate-stakes decisions (neither major nor trivial) that PCPs often face. They have substantive risk/benefit tradeoffs and arise multiple times every day. Further, consider all the substantive decisions surrounding cardiovascular prevention (statins, aspirin, and blood pressure medications: when to start them and which one(s) and at what dose; when to follow-up; when to increase dosing; or when to stop them completely). The list goes on (see supplement for more examples). Substantive, intermediate-stakes decisions in primary care are overwhelmingly numerous and lead to real-time limits en masse. In a recent work, we found that, for a US-representative panel of patients, no PCPs could come close to carrying out detailed SDM for a limited set of highly recommended preventive services, even if they worked long hours and carried a small patient panel.^{7, 15}

Current evidence strongly suggests that most busy PCPs continue to simply jettison SDM and patient-centered care altogether rather than implement available SDM models.^16–18 SDM tools are rarely adopted in routine primary care practice despite intensive implementation efforts.¹⁹ Even randomized trials that have brought more resources to bare have only been able to produce modest impacts at best.²⁰ Something clearly is not working with current SDM models. While prior work has identified a number of important non-time-related barriers to implementing SDM,^{1, 2, 5, 19, 21, 22} other studies paint a clear picture of the impact of competing demands on time allocation in primary care: PCPs typically have 1–2 min for an intermediate-stakes decision that is not the major focus of that day’s clinic visit.^{7, 8, 23–28} Some SDM models have emphasized the time-pressure issue,^{29, 30} but have still not adequately addressed it. In contrast with the time available, even the “brief” SDM approaches involve a minimum of 3–5 min for the initial presentation and often take > 10 min to complete.^30–33 These models are collectively referred to here as detailed SDM, due to the time and depth of the initial presentation. For example, the 3-step SDM approach advocated by Elwyn et al.,^{29, 34} while brief compared with other approaches, still appears to take an average of 4 min and 36 s to cover the initial presentation.³⁰ This level of initial detail may be appropriate for many healthcare decisions, but it is clearly not feasible for most intermediate-stakes primary care decisions.

Some readers will challenge the assumption that SDM needs to be constrained to the 1–2 min available within a typical patient-clinician encounter. Why cannot non-PCP clinic personnel help with a team-based approach to SDM?³⁵ We have no objection to such approaches but note that they continue to be rarely used in routine primary care despite decades of SDM advocacy, and we remain skeptical that this is likely to change in the near future (further comment on this in the supplement).

DEALING WITH LIMITED TIME: “EVERYDAY SDM” FOR PRIMARY CARE

We offer a compromise approach (“everyday SDM”) for these everyday decisions, one based on achievable expectations and achievable process (see Box 2). We have been using and teaching this approach for many years in busy primary care settings, though we hope others will suggest refinements and improvements. The point-of-care implementation of the approach is quite simple (as it needs to be given the severe time-constraints): the PCP starts with a very brief, qualitative initial presentation (< 30 s) that is personalized to the patient’s estimated absolute net risk reduction. Next, the PCP conveys full support for the patient’s right to make the final decision and decline the initial recommendation—only providing details on request. We emphasize 2 critically important tasks for the profession that can support this approach (and all SDM): (1) produce more individualized estimates of net absolute benefit; and (2) produce information on how sensitive the decision is to the range of patient preference seen across patients. Ideally, this information would be made easily available to clinicians during routine practice via systems support that is developed by researchers, guideline groups, or other clinical leaders.

Box 1 Personalizing substantive everyday decisions in primary care

1) Produce individualized estimates of net absolute benefit* (Pre-Visit) •Included in textbooks, clinical guidelines, and point of service decision aids •Estimates of net absolute risk reduction (net ARR) based on RiskNoRx (estimated risk if not treated), RRRRx (treatment’s relative risk reduction from best available evidence, preferably RCTs), and HarmRx (estimated harms if treated) •net ARR = (RiskNoRx * RRRRx) − HarmRx

2) Identify the preference-sensitive zone* (Pre-Visit) •Guideline-level and/or clinician-level deliberation to set a range in which medical intervention is likely to be highly preference-sensitive (a matter of individual patient judgment) vs. likely high-benefit vs. likely net harm/waste

3) Offer “Everyday Shared Decision-Making” (During Visit) a) Initial presentation: personalized and < 30 s •Make a highly personalized recommendation (strength varies with evidence for and magnitude of net benefit) •Encourage high-benefit care, discourage low-benefit care, or inform about how the decision is preference-sensitive and how key factors affect the decision (see supplement for examples) •Briefly present the basis for the recommendation, highlighting key tradeoffs for the patient b) Brief conversation: convey full respect for patient autonomy •On request, ensure patients have access to high-quality decision aids that enhance comprehension of key information •Convey respect for patient preferences •Fully support patient’s right to make the final decision and decline the initial recommendation

*Details on producing individualized estimates of absolute net benefit and identifying the preference-sensitive zone are provided in the supplement

In proposing this approach, we are supporting patient-centered care and respect for patient autonomy as bedrock principles of modern clinical practice, while also recognizing an urgent need for a practical approach that can be completed in 1–2 min. Beyond being more practicable, this approach is designed to foster patient-centered care and meet the transparency standard of informed consent.³⁶ The supplement provides additional details and examples regarding this proposal. Based on our years of experience using this approach in our primary care clinical practice, we feel it is practicable and results in high levels of patient satisfaction.

PRODUCING SYSTEMATIC EVIDENCE TO BETTER SUPPORT ALL SDM

Below, we provide a very brief overview of key points related to producing systematic evidence to aid personalized decision-making. In the supplement, we provide more detail and also provide additional key references that greatly expand on this brief discussion, since there is a large body of prior literature on these topics.

Emphasize Individualized Estimates of Net Absolute Benefit

Without information on the chance of a patient benefiting (e.g., 50 in 100, 1 in 100, or 0.01 in 100), SDM is not really possible.^{37, 38} A large body of prior work has described how to generate individualized estimates of benefit and harm as well as the importance of using individualized information to personalize discussions with individual patients (also see supplement).^39–41

Identify the Gray Area—Where Decisions Are Most Likely to Be Preference-Sensitive

Although decisions are usually discrete (screen vs. do not screen, treat vs. do not treat), the probabilities for benefit and harm are continuous (a 60% chance of benefiting to a 0.001% chance) and include considerable uncertainty. Given this continuum, it is quite illogical and a little disingenuous to pretend there exists a single “bright line” that divides recommend for and recommend against treatment.⁴² Clinicians, and most patients, easily understand that uncertainty in treatment outcomes and individual preferences can create a gray area for medical decision-making. Guidelines and decision support tools should seek to help clinicians identify this gray area (preference-sensitive zone) for common intermediate-stakes decisions in primary care, indicating for whom net benefit is uncertain or for whom patient preference will determine the recommended medical strategy. Providing more continuous information on how preference-sensitive common decisions are, across different individuals in the target population for that intervention, would greatly facilitate everyday SDM (see supplement for examples and discussion of how to identify the preference-sensitive zone).

Decision tools can potentially enhance ability to get information on individualized net benefit and preference-sensitive zones, once available, to the point-of-care to inform patient-clinician discussions (see screenLC.com for an example of a tool designed to generate this individualized information and facilitate personalized lung cancer screening discussions).

Offer “Everyday Shared Decision-Making” to Personalize the Decision

Initial presentation (personalized and < 30 s): In contrast to detailed SDM, our approach emphasizes qualitative information in the initial presentation. Quantitative information (ideally individualized) informs the initial presentation but is not communicated to patients except when they request more detailed information. In our practice, we have tried, and repeatedly failed, to meaningfully communicate numerical estimates of absolute benefit and harm within the time available for everyday decisions. Thus, to keep the initial presentation succinct, our approach focuses on making a highly personalized recommendation and briefly presenting qualitative information about the key tradeoffs for a patient. This approach rejects unchecked paternalism and rejects the idea that clinicians should be passive suppliers of probabilities. Clinicians can be health advocates for their patients while also fully respecting autonomy. For example, we need not feel guilty when making a strong lung cancer screening recommendation to a patient who is an ideal candidate and at the same time should fully respect the patient and their decision if declining such recommendations. Further, a skilled clinician can use language and tone to help communicate the strength of their recommendations. Sometimes we say something like, “For someone like you, I think the potential benefits outweigh the harms” and in other cases “This is very clear-cut, and the benefits far outweigh the potential harms.”

Brief conversation: Explicitly conveying full support for patient autonomy during the brief conversation that takes place after the initial presentation is critical in the everyday SDM approach. Some patients will want detailed information, numbers, and detailed SDM—and clinicians should be provided with such back-up tools to provide it during or after the visit. Also, we think being a respectful health advocate is part of our job. All clinicians have patients decline even strong recommendations (such as a flu shot for someone aged 80), and when you respect the patient’s decision and autonomy, patients rarely resent us being health advocates.

DISCUSSION

Most patients care deeply, and deserve, that their clinician cares for them as an individual.⁴³ The everyday SDM approach is designed to foster that principle and, just as importantly, demonstrate patient-centered care to patients. Some researchers argue that, for most decisions, fully sharing the decision is valued much more by SDM advocates than by most patients.⁴³ They argue that most patients primarily want information, a recommendation, and reassurance that the clinician will respect their right to decline a recommendation. That has certainly been our personal experience.

In conclusion, PCPs need a way to make substantive everyday decisions more patient-centered than what is occurring in current practice. Current proposals tend to recommend detailed SDM for many everyday decisions, and evidence suggests that most clinicians feel this is not practicable. Thus, they often jettison structured shared decision-making altogether. We argue that progress can be made if PCPs were provided better information at the point-of-care (individualized estimates of absolute net benefit and information on preference-sensitive zones) and then offered everyday SDM to their patients. This approach can also be used for tough decisions that lack a good evidence base. The everyday SDM approach we have proposed is designed to succinctly communicate to patients “I’ve thought about the degree of benefit for you specifically,” allows clinicians to continue being gentle health advocates and demonstrates support for patient autonomy. We think that most PCPs will welcome making small changes to how they address everyday decisions, if they feel the changes are realistic.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.