Friday, November 13, 2015

How care teams can support shared decision making in primary care (1 of 2)

Earlier this afternoon, I delivered the keynote speech at the Team Care Challenge, sponsored by the Patient-Centered Primary Care Collaborative, Medstro, and the American Resident Project. This is the first of two posts containing the text of my talk. Part 2 is posted here.


Good afternoon. Thank you for inviting me here today to speak to you about primary care teams. I was really inspired by all of today’s presentations, and I’m glad that I am not one of the judges, because it would have been a very tough choice!

You have all probably heard something about the White House’s Precision Medicine Initiative. I have expressed skepticism about this initiative because I think that focusing on differences in our genomes will divert attention and funding from social determinants of health that are far more powerful predictors of illness and wellness. The term “precision medicine” is often used interchangeably with “personalized medicine.” That’s too bad, since I would argue that family physicians and other primary care clinicians have been providing personalized medicine long before genomic medicine existed, approaching our patients as individuals with unique backgrounds, values, and preferences that can and should affect the care we provide. One powerful approach to providing this type of personalized care is shared decision-making.

What I’d like to talk about today is how care teams can support patients and health professionals in making shared decisions.

So what have been the big health news stories with implications for the practice of primary care over the past year? For me, three come immediately to mind.

#1. End-of-life counseling. Five years after the phony political uproar over “death panels” that were never included in any health reform legislation, Medicare will finally pay doctors to counsel patients about advance care planning and end-of-life options. This is welcome news.

#2. Breast cancer screening. After decades of insisting that all women at average risk undergo mammograms every year starting at age 40, the American Cancer Society relaxed its guidelines. They now agree with the U.S. Preventive Services Task Force that mammography should be optional for women in their early 40s and that every two years is a more beneficial interval for screening in women older than 55.

#3. Lower blood pressure goals. The NIH-sponsored SPRINT study showed that lower blood pressure goals may be better in some patients over 50 who are at high risk for cardiovascular events. Over a little more than 3 years of follow-up, about 60 people needed to be treated to a systolic BP of 120 to prevent one cardiovascular event or stroke compared to the traditional target of 140. On the flip side, more intensive treatment was associated with one more episode of severe hypotension, one case of syncope, and two more episodes of acute kidney injury for every 100 people.

The one thing that these stories all have in common is that they envision an increased role for shared decision making in primary care.

Some patients will want to receive few aggressive interventions at the end of life, some will want more.

Some women will be fine with waiting until age 45 or 50 to get their first mammogram, some will still want to start at 40.

For some patients, reducing their risk of heart attack or stroke will be worth the price of taking one extra medication and the associated adverse effects. For some patients, it won’t be.

It will be the primary care team’s job to guide patients in making these difficult health decisions.

I will admit to you right now that I’m no expert on shared decision making, and I consider myself to be mediocre at best in engaging patients in this process. Despite the many lectures I’ve given about why patients should think about foregoing PSA screening or mammograms due to the well-documented harms that can result from both tests, I still struggle to explain the relative pros and cons of competing choices and help my own patients pick one or the other. In part, this is because making shared decisions is naturally difficult. But I’ve started thinking that it may be harder than it needs to be because I’m usually trying to do it alone.

So how could a primary care team support shared decision making? A 2012 article in Family Practice Management identified six key characteristics of effective practice teams. These were: shared goals, clearly defined roles, shared knowledge and skills, effective and timely communication, mutual respect, and an optimistic can-do attitude. Effective primary care teams delegate responsibilities so that each staff member does only what he or she is uniquely trained to do, rather than wasting time and energy on tasks that can be performed more efficiently by other team members.