Enhancing Physician Competencies for Shared Decision Making in Primary Care

FIMDM Investigator Initiated Grant 0143-1

Research Team

Principal Investigators

Robert J. Volk, PhDMD Anderson Cancer Center

Navkiran Shokar, MDTexas Tech Health Sciences Center

ConsultantPatricia Dolan Mullen, DrPHUniversity of Texas Health Sciences Center

at Houston

Co-investigatorsGurjeet S. Shokar, MDTexas Tech Health Sciences Center

Robert J. Bulik, PhDBarbara G. Ferrell, PhDUniversity of Texas Medical Branch

Viola Leal, BASuzanne K. Linder, PhDMD Anderson Cancer Center

Background

• Patients generally want to be involved in decision making about their health.

• SDM is occurring to a very limited extent in routine primary care practice.

• Emerging evidence supports effectiveness of training programs in SDM skills.

• Web-based cases have been shown to be effective in medical education.

Project Aims

1. Identify skills physicians need to develop, and key behaviors they should exhibit, for promoting shared decision making with their patients.

2. Develop a web-based educational curriculum using Design A Case (DAC©) software to improve physician competencies for shared decision making in routine practice.

3. Implement and evaluate the educational program in a sample of primary care physicians.

Aim 1

Identifying Competencies for SDM

Methods for identifying sources

1. Contact leaders in SDM training (Legare, O’Connor, etc).

2. Literature search for training programs, conceptual frameworks, and measurement systems.

3. Search conference presentations / abstracts (ISDM ’09, SIIPC ’08).

Selected sources for generating SDM competencies

Coding Systems• IDM-18 (Braddock)• DSAT (O’Connor)• DAS-O (Butow)• OPTION (Elwyn)

Training Programs• Peer coaching (Gattelari)• DECISION+ (Legare)• ODST (Ottawa)• Train-the-Trainer (Harter)

Frameworks• CDC IDM definition (Briss)• Competencies for IDM (Towle)• Integrative Model of SDM

(Makoul)• Shared Treatment Model

(Charles)

Sorting of competencies into key behaviors, themes, and steps

17 themes sequenced into 6 steps + 4

overarching themes

Key behaviors sorted into 21 themes

Similar statements reworded to form key

behaviors

Unique competency statements identified 199

62

21

17 4

1. Describe the Need for a Decision

Describe the health issue or

decision.

Communicate uncertainty.

Emphasize the need for a decision.

2. Review the Options

Discuss the options.

Provide a balanced

explanation of the pros and cons of

each option.

Provide probabilities

using accepted principles of risk communication.

Assess the patient’s

comprehension.

3. Explore Patient's Values

Discuss the patient’s views of

the options.

Explore the patient's values.

4. Determine Patient's

Preferred Role

Assess the patient's preferred role in making the

decision.

5. Negotiate a Course of

Action

Assess the patient’s

readiness to make a decision.

Elicit the patient's initial preferences

for the options.

If the patient prefers, provide a recommendation

about which option seems best

for the patient.

Negotiate with the patient a mutually

agreed upon course of action.

6. Make Plans for Follow-Up

Help undecided patients access

additional support and other

resources to make the decision.

Make a plan to review the decision or deferment.

Document in the medical record that a discussion about

the problem occurred, whether a patient decision aid was used, and what decision was made.

OverarchingThemes

Six Steps in the Shared Decision Making Process

Encourage patient questions.

Provide guidance in the decision

making process.Tailor information

to the patient. Establish a

partnership with the patient.

Aim 2 – Develop the Case

PSA as a case model – ugh!

Web-based Case Learning:Design A Case (DAC©)

• Interactive, web-based authoring tool– Simulates clinical setting

using standardized linear format

– Case-based learning– Critical reasoning skills and

reflective thinking

• Interactive, web-based authoring tool– Simulates clinical setting

using standardized linear format

– Case-based learning– Critical reasoning skills and

reflective thinking

• Used with clerkship students• Over 50 peer-reviewed cases

in library• Associated with improved

Board scores

• Used with clerkship students• Over 50 peer-reviewed cases

in library• Associated with improved

Board scores

Case development process

Team training

in DAC©

Case story-

boarding

• content

• sequence

• flow

• features

Peer Review by

SDM / PCS

experts*

Peer Review by

DAC© education-al expert

Pilot testing with

physicians

• content

• usability

• relevance

Major redesign

* New step for this project.

Peer review feedback and pilot testing

√ Presentation√ Bigger font size, less text, more visuals (slides, graphics)

√ Sequencing√ Place elements (steps) up front - visual

√ Content√ Add module on decision aids √ Hyperlink to key sources in IDM / SDM literature

e.g., Braddock et al, IDM-18; Barry et al, J Law Med Ethics.√ Hyperlink to key resources / tools

√ Relevance√ Would not select this case for CME – suggested it be offered as ethics

CME

Case features

Case demonstration

www.designacase.org

Case - Elements of SDM

Case – Faculty response feature

Case – Linked sources and clinical pearls features

Aim 3 - Evaluation strategy

• Email invitation from NRN to membership (snowball effect)

• Interested members received email instructions with unique password

• Case completed - online• Link to evaluation form (SurveyMonkey)• Separate link to reimbursement form

Evaluation framework

Kirkpatrick & Hawk. Evaluation framework for learning. June 2006.

Reaction / satisfaction

• Rating objectives

• Case structure /features

Learning

• Knowledge of SDM steps & DAs

• Confidence in SDM

Behavior / application

• Intention to perform SDM behaviors

Results / outcomes

Who participated (n=49)

• Specialty– Family medicine

79.6%– Internal medicine

4.1%– Nurse practitioner

2.0%– Other clinicians

14.3%

• Male (53.1%)*

• Affiliated with an academic center 55.1%

• Currently in a residency program 24.5%

• Length of time in practice– Mean, 17.2 y– Range, 4 to 35 y

* 1 participant did not indicate gender.

Ratings of the Case

Completed all modules 100% Length about right 82%

Case met objectives 98% Used links to other info 63%

Help understand SDM 96% Links helpful 90%

Not relevant to practice 4%

Well organized 98%

Recommend to others 84%

General knowledge of SDM (% correct)

SDM is a process between patient and provider in which both parties express values and participate in making a decision.

83.7

The clinician alone is best equipped to make the final decision.* 100.0

An equipoise decision is one where the scientific evidence does not favor one option over another. 95.6

* Correct response is false.

Correct identification of steps in SDM process (% correct)

Describe need for a decision. 95.2

Describe options. 100.0

Described one best option to the patient.* 93.9

Explore the patient’s values. 100.0

Determine the patient’s preferred role. 95.9

Negotiate a course of action. 91.8

Make plans for follow-up. 100.0

* Not a step in SDM process.

Overall confidence in performing SDM

0

10

20

30

40

50

60

70

Very confident Somewhat confident Not very confident

69.4

30.6

0

%

“Very Confident” in performing SDM steps

Percent

Intention to perform SDM behaviors (for PC screening)

Percent

Conclusions

• A case-based, online, interactive educational program on SDM skills is well-received by primary care clinicians.

• Knowledge of SDM processes demonstrated.

• Clinicians appear confident in performing steps of SDM (lowest for role preferences and values).

• Some suggestion that clinicians plan to utilize SDM processes with their patients.

Remaining questions

1. Are there better case models?

2. Assessing preferred role and patients’ values remains a challenge – modeling / video?

3. Is a “single infusion” sufficient to promote SDM behaviors? Unlikely.

Might the case be part of a multicomponent training program, within a longitudinal experience?

4. Is ethics CME the way to go for broad dissemination?

Thank you

Questions

Additional findings related to patient decision aids

Knowledge of Patient Decision Aids

Decision aids… % correct

help patients understand their options. 97.9

help patients understand the harms and benefits of the options. 98.0

help people think about choices. 98.0

provide information about options. 98.0

help people to deliberate. 77.6

support people to forecast how they might feel. 61.2

help the process of constructing preferences. 85.7

Knowledge of Outcomes for Patients who Receive Decision Aids

Patients who receive decision aids … % correct

tend to be less involved with their care.* 95.9

tend to become more anxious about their choices.* 85.7

tend to be clearer about what choice is best for them. 89.8

* Correct response was false.

Before this Case, were you aware of patient decision aids?

0102030405060708090

100

yes no unsure

%

Do you currently use patient decision aids in your practice?

0102030405060708090

100

yes no unsure

%

Do you think patient decision aids are helpful in practice?

0102030405060708090

100

yes no unsure

%