Shared decision making (SDM) involves physicians and patients collaboratively discussing potential management strategies when there is more than one reasonable treatment option to consider. Together, decisions are reached based on the available evidence and patient preference. “SDM can enhance patient knowledge and satisfaction and help ensure that medical decisions are closely aligned with patients’ values,” explains Hemal K. Kanzaria, MD, MS.
It can be challenging to integrate SDM into ED care because of its fast-paced environment. In addition, EDs must manage high-acuity patients and there are varying levels of treatment uncertainty throughout emergency medicine (EM). For example, EPs may face pressure to make rapid decisions to increase throughput. Some ED patients may also be unable to seek decision-making help from family, friends, and trusted individuals. Furthermore, patients may express that they want their clinicians take a more dominant role in decision-making when the stakes are high.
Studies analyzing SDM in EM have shown that this approach appears to be feasible and that many of these challenges can be overcome. “Greater efforts are being made to achieve patient-centered care with SDM, but few studies have examined the viewpoints of frontline EM physicians,” says Dr. Kanzaria. “A better understanding of the perceptions of EPs on this topic is critical to increasing adoption of SDM in EM.”
Surveying Emergency Physicians
In a study published in Academic Emergency Medicine, Dr. Kanzaria and colleagues surveyed EPs on the frequency with which SDM may be appropriate in their clinical practice. The authors also examined perceptions on the potential for SDM to reduce medically unnecessary diagnostic testing, the barriers to employing SDM in the ED, and the association between perceived barriers to SDM and self-reported use of it. “Surveyed EPs believed that there were multiple reasonable management options in over 50% of their patients,” says Dr. Kanzaria. “This suggests there is great opportunity for integrating SDM in emergency care.”
EPs endorsed SDM as a promising solution to reduce over-testing, according to the study, but many respondents perceived that patients often prefer to have their physicians make decisions (Table 1). “EPs also believed that—when offered a choice—patients may opt for more aggressive care than is actually needed,” Dr. Kanzaria says. “Others indicated that it would be too complicated for patients to know how to choose. The main perceived barriers to engaging patients were patient-related.”
The study also revealed that EPs who more strongly endorsed barriers to SDM were less likely to report personally using it in their own practice. For example, physicians who “agreed” or “strongly agreed” with the statement that “many patients prefer doctors to decide what to do” reported less use of SDM in their own practice when compared with EPs who “disagreed” or “strongly disagreed” with the statement. This relationship between endorsement of a barrier and decreased use of SDM was also true for other barrier statements (Table 2).
Analyzing the Implications
Recently, a call to action has been issued in EM to provide high-value, cost-conscious care. This initiative also endorses the use of SDM tools. As such, Dr. Kanzaria says it is important to understand the beliefs of EPs on the barriers they face to achieving this goal. “It would be inappropriate to promote SDM primarily as a cost-saving measure,” he says. “However, SDM should be viewed as a helpful approach to ensure that patients have an opportunity to choose care that is most suitable for them when reasonable options exist.”
Although it is encouraging that many EPs feel they are engaging patients in a collaborative decision-making process, Dr. Kanzaria says there is room for improvement. The results of the study suggest that SDM is not universally practiced in a substantial number of patients in whom it would be appropriate. “Ultimately, our goal should be to engage all patients in their care, to the degree that they wish, given the appropriate clinical situation,” Dr. Kanzaria says.
More studies are needed to explore the extent and manner to which ED patients want to be involved in emergency care decisions, according to Dr. Kanzaria. “Both physicians and patients should be aware of the potential value of SDM,” he says. “There also needs to be a cultural shift within medicine to facilitate true patient engagement. It should be routine to ask patients if and how they want to be involved in their healthcare decisions.”
Kanzaria HK, Hoffman JR, Probst MA, Caloyeras JP, Berry SH, Brook RH. Emergency physician perceptions of medically unnecessary advanced diagnostic imaging. Acad Emerg Med. 2015;22:390-398.
Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27:1361-1367.
Oshima Lee E, Emanuel EJ. Shared decision making to improve care and reduce costs. N Engl J Med. 2013;368:6-8.