One of the most notable things so many of last year’s biggest health stories 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; others will want more. Some women will be fine with waiting until age 45 or 50 to get their first mammogram; others 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 other 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.
Let’s take each of these clinical scenarios I brought up one by one. I prescribe medications for high blood pressure all the time, I’m familiar with the current treatment guidelines, and I have a pretty good grasp of the most common side effects. But I would wager that most clinical pharmacists know at least as much as I do about these drugs, if not more. Rather than relegating these team members to the role of dispensing prescriptions, why not co-locate them in large primary care practices, or use FaceTime or Skype for real-time consultations? Based on the eligibility criteria for the SPRINT study, my office could create screening protocols for medical assistants or licensed practical nurses to identify eligible patients at the time of check-in, just as they already pre-review immunization records to see who might need shots that day.
How about the question of when a woman should start screening mammograms? In this situation, competing guidelines make getting to the answer even more complex. But we should keep in mind that the starting and stopping ages in breast cancer screening guidelines were set by guideline developers who applied their own preferences and values to the balance of benefits and harms. We can do better than “what most women would want” — we should find out what the patient in front of us wants. The primary care team could create an agreed-on protocol in which a woman of a certain age could automatically be given a print or electronic decision aid at the time of a health maintenance visit. Medical assistants could ask initial questions about their preferences and concerns and document these in the chart so that when it was time to have the discussion and make a decision, the patient and clinician would already be on the same page.
Advance care planning is perhaps the most emotionally and logistically challenging scenario. Medicare says that we can have these discussions with the patient at a stand-alone visit, a wellness visit, or a visit for management of chronic medical issues. In this situation, I envision the primary care team playing a vital behind-the-scenes role. My team members can remind me that I’ve never had this sort of discussion with Mr. Jones or Mrs. Smith, and give me an extra nudge if Mr. Jones or Mrs. Smith is over 65 or has one or more of several life-limiting health conditions. Or perhaps the patient’s advanced directive is several years old, and it’s time to revisit it to make sure it still aligns with his or her wishes. To support shared decision-making, my team can make sure that I have a blank copy of an advanced directive on hand, and that helpful videos and other educational resources are already open on the desktop computer in the examination room. This way I can focus completely on the patient rather than fumbling around for missing materials or forms.
Now what I’ve just told you is the way I wish things were rather than the way they really are in my practice, and in most primary care practices — even those that, like mine, have achieved certification as a “patient-centered medical home.” Don’t get me wrong, I am all for the PCMH, but I view it as a set of minimum requirements rather than aspirational goals.
And unfortunately, much of what I’ve described would be thwarted by our current, antiquated payment system that only assigns value (and dollars) to the things that doctors do. Who’s going to pay for the clinical pharmacist to spend all day in the outpatient setting providing medication counseling? Who’s going to pay for the extra medical assistant the practice must hire now that there’s a lot more to do than checking patients in and taking their vital signs? Who’s going to pay for the home blood pressure monitor and the extra time the practice spends text messaging or on phone calls needed to intensify blood pressure treatment in patients who choose to do so?
This is where all of you come in — and by “all of you,” I mean students and trainees just as much as the practicing clinicians. Choosing a career in medicine today means that you already have a vision of the possibilities of team-based primary care that is far more expansive than mine was when I was in training. It will be up to your generation to advocate for changes in healthcare payment and practice organization that empower primary care teams to reach their full potential to support routine shared decision-making. The direct primary care movement may be one answer. Insurers paying practices for health outcomes, rather than numbers of encounters or specific providers of services, is another.
There are countless creative ways we can put patients back at the center of care where they belong. All of these transformative ideas have this principle in common: They will work best when carried out by high-functioning care teams.
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