Dermatologists point to barriers to implementation despite improved patient satisfaction

A scoping review found that shared decision-making (SDM) is a powerful tool for providing patient-centered dermatologic care and leads to improved patient satisfaction — however, the review authors found that there are barriers to dermatologists incorporating SDM into their practice that need exploring.

SDM has been proven to improve the quality of patient care, allowing physicians and patients to collaborate on treatment plans and enhancing patient knowledge, satisfaction, and treatment adherence, Erin Foster, MD, PhD, of Oregon Health & Science University Center for Health & Healing in Portland, Oregon, and colleagues explained in JAMA Dermatology. In their review, Foster and colleagues systematically assessed the extent to which SDM is utilized in the dermatology setting, and the evidence supporting its use.

“Most patients are interested in SDM conversations focusing on costs, safety, tolerability, and individual concerns, and patients appreciate physician attributes of knowledgeability, empathy, and a willingness to have the conversation,” they wrote. “In our review, we found that physicians who use SDM noted improved patient satisfaction; however, there were concerns about time as well as an insufficient amount of training on the subject.

“Consequently, the larger question is why dermatologists are reluctant to use SDM in their daily practice,” they added.

In the studies assessed in their review, dermatologists expressed concerns about time and a lack of proper training, as well as a general lack of familiarity, as the primary barriers limiting SDM implementation.

“Dermatology is a fast-paced field, and the reliance for billing on a rapid turnover of patients would seem to discourage even the most earnest dermatologist from engaging in SDM,” they wrote.

In an accompanying editorial, Carrie C. Coughlin, MD, and Mary C. Politi, PhD, both of Washington University in St. Louis School of Medicine, St. Louis, Missouri, noted that the barriers to SDM noted by reviewers Foster and colleagues are not unique to dermatology, and that limited clinician training, knowledge, and confidence are perhaps the most important barriers to implementation. They argued that “clinician training in SDM and patient decision aids should include a mixture of didactics and hands-on role playing to allow clinicians and staff to practice and build self-confidence adopting the approach. Resident training, annual meetings, and short courses can start the training process; providing ongoing feedback and support can reinforce learning. Strategies to work the practice into routine care should be tailored to each clinician and clinical workflow.”

For their scoping review, Foster and colleagues screened a total of 1,673 titles and abstracts from Ovid MEDLINE, PsycINFO, PsycARTICLES, Sciverse Scopus, and EBM Reviews—of these, only 29 articles were included in the analysis. The review authors used qualitative coding on study excerpts to “categorize the article, define and describe advantages and disadvantages of SDM, understand patient and physician requests for SDM, and discuss methods of implementation,” they explained.

“Despite a small number of articles on SDM (n = 29) in dermatology, the selected literature provided consistent messages regarding the importance of SDM for dermatology and a number of strategies and tools for implementation,” they found. “Medical dermatology was the most common subspecialty studied, with melanoma, psoriasis, and connective tissue diseases most examined. Only 5 publications introduced SDM tools specifically for dermatologic conditions; of these, only 2 tools were validated. Barriers to implementation that were cited included time and a lack of training for clinicians, although the literature also provided potential solutions to these issues. All articles emphasized the value of SDM for both patients and physicians.”

They added that patient attitudes towards SDM were positive across the board, writing that “Most patients are interested in SDM conversations focusing on costs, safety, tolerability, and individual concerns, and patients appreciate physician attributes of knowledgeability, empathy, and a willingness to have the conversation.” Notably, most physicians who used SDM noted improvements in patient satisfaction.

The two validated SDM tools identified in this review included a pair of patient decision aids (PDAs), one for acne and one for psoriasis, both of which were validated by the International Patient Decision Aid Standards.

Foster and colleagues noted that, while the amount of time SDM is anticipated to take was the most frequently cited barrier to implementation, many articles pointed to saving time as an advantage of the practice — initially lengthy decision-making consultations were offset by future time savings, as patients required fewer or shorter follow-up consultations.

The other most common barrier to SDM was a lack of training and awareness, and the reviewers noted that age was a factor in this issue: “a younger physician demonstrated better improvements in patients’ knowledge after implementing PDAs than older physicians.” Foster and colleagues suggested that facilities implement an active training process for medical students, residents, and physicians to improve skills and confidence in offering personalized patient support, and that clinicians should be equipped with up-to-date decision support tools that are relevant to their patients.

To help overcome these barriers, the review authors suggested adding ability to use SDM to the competencies required for graduation from residency in order to increase familiarity and confidence—meanwhile, for dermatologists who are already practicing, they suggested expanding course offerings for continuing medical education credit to focus on conditions commonly seen in specialty practice.

They also noted that support from insurers and other financial incentives may increase the use and continued development of relevant PDAs, and that Centers for Medicare & Medicaid Services requirements for the use of SDM prior to reimbursement for certain procedures might help facilitate rapid integration. Moreover, as many patients are likely not aware of SDM or the availability of different treatment options, clinicians should inform patients of all viable treatment options and assess the patient’s interest in taking part in final treatment decisions.

“Noticing and documenting a positive outcome in patient care is a key motivator of incorporating SDM and patient decision aids,” Coughlin and Politi noted in their editorial. “Shared decision-making and patient decision aids can decrease decisional regret, decrease decisional conflict, and increase patients’ confidence in decisions when applied in other areas of medicine. It is clear from the review that patients desire this process in dermatologic care, and engaging patients through SDM, with or without patient decision aids, is imperative. More work is needed to develop, test, and implement SDM and patient decision aids to meet patients’ calls for involvement and improve the quality of care in dermatology.”

Limitations to the review by Foster and colleagues included limiting their search string to interactions between physicians and patients and excluding midlevel professionals, such as nurses; the publication of a new PDA between the review date and the current publication; and a lack of search coverage for continuing medical education, search-specific dermatologic conditions, and material available to patients online via search engines and non-peer-reviewed publications, “which are a core element of SDM.”

  1. A scoping review found that shared decision-making (SDM) is a useful tool in dermatology care and leads to improved patient satisfaction—however, dermatologists cited barriers to implementing SDM that warrant attention.

  2. More resources and education in SDM are needed in order to assist dermatologists in fully incorporating SDM into clinical practice.

John McKenna, Associate Editor, BreakingMED™

Review coauthor Simpson reported receiving personal fees and grants from AbbVie, Eli Lilly, Incyte, Kyowa Hakko Kirin, Leo Pharmaceuticals, Merck, Pfizer, Regeneron, Sanofi, Tioga, grants from Novartis and Vanda, and personal fees from Boehringer-Ingelheim, Collective Acument LLC, Forte Bio, Janssen, Ortho Dermatologics, Pierre Fabre Dermo Cosmetique, Roivant, and Valeant outside the submitted work.

Politi reported receiving grants from Merck outside the submitted work.

Coughlin reported no disclosures.

Cat ID: 105

Topic ID: 75,105,556,730,105,192,925