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Tammy Hoffmann1,2, Chris Del Mar1, Victor Montori 3 1 Centre for Research in Evidence-Based Practice, Bond University, Australia , 2 SHRS,
University of Queensland, Australia, 3 Mayo Clinic, USA
Integrating the teaching of shared decision making
into
the teaching of
evidence-based practice
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1. To raise awareness of the link between shared decision making and EBP and why shared decision making skills should be explicitly taught, and how they can be logically incorporated into EBP teaching
2. To overview strategies and tools for teaching and assessing shared decision making core skills
Theme group tomorrow → Integrating the teaching of shared decision making into the teaching of EBP: why, how and what else do we need to know?
Workshop objectives
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• What does SDM have to do with EBP? • What are some of the skills needed for SDM? • Strategies and tools for facilitating SDM • Some ideas for how to teach and assess these skills
• Others?
Main topics
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What does SDM have to do with EBP?
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One way of conceptualising the link…
from Hoffmann, T., Bennett, S., & Del Mar, C. (2013). Evidence-based Practice across the Health Professions. (2nd ed)
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Aware Accepted Applicable Able Acted on Agreed Adhered to
Unsound
Research
Sound
Research (3)
Another way: Evidence-to-Practice Pipeline
Glasziou, P., & Haynes, B. (2005). The paths from research to improved outcomes. Evidence-Based Medicine, 10: 4-7.
Studies (primary research: sound & unsound)
Systems (bottomline +/- ref)
Synopses (user summary of research)
Systematic Reviews & CATs (search; appraise; synthesis)
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A benefit of shared decision making…
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Shared decision making
Decision aids
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Conditions with decision aids evaluated in RCTs…
Stacey D, Bennett C, Barry M, Col N, Eden K, Lyddiatt A, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2012;
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“ A good level of SDM occurs about 10% of
the time”
Couët N, et al. Assessments of the extent to which health-care providers involve patients in decision making: a systematic review of studies using the OPTION instrument. Health Expectations, 2013;14.
SR of 33 studies mean OPTION (Observing Patient Involvement in Decision Making, 0-100) score = 23
Godolphin, W. Shared decision making. Healthcare Quarterly; 2009:12, e186-90.
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• Lack of time • “We already do SDM” • Not sure what it really is • Not clear what it is meant to achieve • “It doesn’t make any difference to outcomes” • “Most of my patients don’t want to be that involved”
Solutions:
Barriers to SDM… & training
Patient-mediated interventions e.g. decision support tools or training in questions to ask
Health professional training in SDM
Legare, F, et al. Barriers and facilitators to implementing shared decision making in clinical practice: Update of a systematic review of health professionals’ perceptions. Pat Educ Couns, 2008; 73:526-35. Towle, A., & Godolphin, W. Putting informed and shared decision making into practice. Health Expectations, 2006; 9:321-2.
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Is it typically taught to student clinicians and clinicians?
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The teaching of SDM skills…
Patient communication
skills
Evidence-based practice skills
SDM skills
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Shared decision making: A skill that needs to be taught
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When should SDM be taught?
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• Time when health professionals acquire their professional identity
• Time when interview and consultation ‘scripts’ and
habits are developed • ‘Hidden’ curriculum – trained to believe it is
important to have “the answer” • Lack of role models who practice SDM
Why teach SDM to undergraduates?
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• Most likely not taught when undergraduate
• Lack of training is a major barrier to SDM occurring
Why offer SDM training as CPD?
Légaré F, Bekker H, Desroches S, Drolet R, Politi MC, Stacey D, et al. How can continuing professional development better promote shared decision-making? Perspectives from an international collaboration. Implement Sci 2011;6:68. Légaré F, Politi MC, Drolet R, Desroches S, Stacey D, Bekker H. Training health professionals in shared decision-making: An international environmental scan. Patient Educ Couns 2012;88:159–69.
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• Skills that are needed by all clinicians
• Systematic review of facilitators and barriers to the implementation of shared decision making (Légaré et al
2008):
~ 90% of all study participants were physicians
Who should be taught?
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What should be taught?
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What are some of the steps & skills needed?
Developing a
partnership
with the patient
Determining patient’s
preferences for information (amount &
format)
Determining patient’s
preferences for
his/her role in decision making
Eliciting and responding to
patient’s ideas, concerns,
expectations
Discussing
options,
along with the benefit/s and
harm/s of each
Presenting
likelihood of
benefits and harm/s,
individualising where possible
Helping patient reflect on options
& impact of alternative decisions,
considering values and lifestyle
Checking understanding;
supporting negotiating a decision or
agreeing to defer
Agreeing upon an action plan
& arranging follow-up/ review as needed
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• Current debate about ‘core’ skills • Agreement about 2 broad areas of competencies:
– Relational skills – Risk communication skills
Core skills?
Légaré. F., Moumjid-Ferdjaoui, N., Drolet, R., Stacey, D., Härter, M. Core competencies for shared decision making training programs: insights from an international, interdisciplinary working group. J Contin Educ Health Prof. In press.
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One model: Choice, option, decision talk
Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared decision making: a model for clinical practice. J Gen Int Med 2012;27:1361–7.
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• What will happen if I wait and watch? • What are my test or treatment options? • What are the benefits and harms of these options? • How do the benefits and harms weigh up for me? • Do I have enough information to make a choice?
5 Questions
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Key steps to communicating evidence
General strategies and skills for effectively communicating with patients
+ 1. Understand the patient’s experiences and expectations 2. Build partnerships 3. Discuss the evidence, including a balanced discussion about
uncertainties 4. Present recommendations 5. Check for understanding and agreement
Epstein, R., et al. (2004). Communicating evidence for participatory decision making. JAMA, 291:2359-66.
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Teaching ‘communicating numbers’ skill
• Tips and tricks • What to teach, resources to use, etc
HOFFMANN, T., & Tooth, L. (2013). Talking with patients about evidence. In T. Hoffmann, S. Bennett, & C. Del Mar (eds). Evidence-based practice across the health professions (2nd ed). Sydney: Elsevier. pp. 328-352.
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• Even when decision aids are available and
appropriate, their use is not straightforward and training health professionals in their use may be needed.
• Various types of decision support tools available • Finding them… • Appraising them…
Decision support tools
Tiedje K, et al. “They leave at least believing they had a part in the discussion”: Understanding decision aid use and patient-clinician decision-making through qualitative research. Patient Educ Couns. 2013;93:86–94.
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Registry of decision aids • http://decisionaid.ohri.ca/resources.html
Decision support tools
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What do we know about how to
teach SDM to students?
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• Hoffmann, Del Mar, et al. (under review) Brief training of student clinicians in shared decision making: a randomised controlled trial.
• Han, et al. Development and evaluation of a risk
communication curriculum for medical students, Pat Educ Couns, 2013.
• Morrow, et al. Shared decision making: Skill acquisition
for Year III Medical Students. Fam Med, 2011; 43:721-5.
Studies to date of teaching students…
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• Already full curricula (in EBP course & elsewhere) • But important topic! • Brief intervention needed • Have always taught this topic/skills, but was it effective?
Background to Hoffmann et al RCT
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For Discussion …