In medicine, many diagnostic questions can be answered in yes or no, black and white terms. Is the pain in your back and legs due to a herniated disc? Is your cholesterol too high?
When it comes to determining the best treatment plan for each patient, however, there are many more shades of gray.
For a herniated disc, is the best course of action to fix the disc via surgery, which could provide quicker relief but may cause a serious complication? Or is it better to manage the pain through physical therapy, which is less invasive than surgery, but may not solve the problem?
If you have high cholesterol, should you take statin drugs, which are effective but can cause side effects such as pain and muscle fatigue? Or to try improving your diet and exercising more, which is often easier said than done?
“In medicine, there are tradeoffs everywhere you look,” says Karen Sepucha, PhD, Director of the Health Decisions Sciences Center (HDSC) at Massachusetts General Hospital. “We can’t know what’s best for someone unless we know who that person is, what’s important to them, and how they might view the tradeoffs. Patients may make different decisions than their provider would when faced with the same situation.”
To acknowledge these tradeoffs and prompt more productive discussions between patients and their providers, the HDSC team has created a series of print, online and video-based decision aids for patients with conditions such as herniated discs, high blood pressure, depression, diabetes, breast cancer, prostate cancer, anxiety and more.
The goal of this approach, called Shared Decision Making, is to present the patient with an objective view of all treatment options, and discuss the pros and cons of each.
“It’s like being able to consult the best doctors and hear from a range of ‘experienced’ individuals who have chosen different approaches. You can learn what the different treatments are like and why folks might make different decisions based on what is most important to them,” Sepucha explains.
The HDSC team also works with clinicians and health care providers to assist them with implementing decision-making tools in their practices. According to Leigh Simmons, MD, an internal medicine physician at Mass General and member of the HDSC team, the process is not always easy.
Simmons explains that many clinicians who already feel strapped for time in their daily practice worry that their patient visits will become longer if they have to address all of the questions that a decision aid can raise.
In practice, however, patient visits tend to stay the same length when a decision aid is distributed beforehand, Simmons says. “It’s the nature of the conversation that changes.”
Clinicians find that they don’t have to spend as much time going through the basics of the medical problem or treatment plan, and can talk more about the pros and cons of each option to see what will work best for each patient. “We usually advise that using a decision aid may not necessarily save time, but it makes for a better conversation with their patients, which everyone likes more, Simmons says. “The questions that get asked are more advanced, and the visit is more productive.”
Another barrier that physicians have to confront is that when you give your patients high-quality information about reasonable treatment options, they may choose something you would not have chosen for them, Simmons says. “That is something we have to be aware of and be honest with ourselves as doctors, and we recognize that sometimes our patients know best about what is right for them.”
From a research standpoint, the HDSC team is working on strategies to determine if decision-making aids are increasing patient involvement and improving treatment outcomes, Sepucha says. “Are patients more informed, are they more engaged in the decision-making process and are clinicians doing a good job of matching the right patient to the right treatment?”
“How we make decisions with our patients is important, and some of our research has shown that our patients who are well-informed and received their preferred treatment have better outcomes.”
For more information about the Health Decisions Sciences Program, please visit www.massgeneral.org/decisionsciences.