Re-envisioning shared decision making in primary care

bbag-icon-decRe-envisioning shared decision making in primary care

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Shared decision making is increasingly advocated as the best approach to patient care for many if not most medical decisions. Yet, actually implementing shared decision making in the primary care setting has remained vexingly elusive. This talk will explore the following questions: Can shared decision making include a primary care provider’s recommendation? If so, how can care recommendations be tailored to be more patient-centered?

apr-13-bbag.jpgJoin us for Tanner Caverly’s lecture on Wednesday, April 13, 2016 from noon till 1 pm in person or online.

Tanner Caverly, MD, MPH, is a general internist and health services researcher at the University of Michigan and Ann Arbor VA Center for Clinical Management Research. In 2012 Dr. Caverly co-founded the Do No Harm Project – an award-winning program that uses clinical vignettes written by clinical trainees to improve recognition of the harms that can result from medical overuse. His research explores the general question: How can population evidence and clinical practice guidelines be better translated for and communicated to patients? In both his teaching and research, Dr. Caverly strives to promote the vision set out by Dr. Bernard Lown to do “as much as possible for the patient and as little as possible to the patient.”

In person: This lecture will take place in C102 East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? All webinars are recorded! View our archive of recorded lectures.

What ethical issues are raised by the uncertainty inherent in prognosis?

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“How long do I have, Doc?”
Ethical Issues in Prognostication for Older Adults

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Making predictions is part of every domain of life, including health care, and when the prediction of healthcare outcomes influences the decisions that are made or the actions that are taken as a result of the prediction, these predictions take on ethical dimensions. Dr. Smith will begin with a brief historical overview, describing the waning of the importance of prognosis in medicine over time. This will lead to a description of the importance of prognosis in palliative care and geriatrics. Dr. Smith will also address ethical issues raised by the uncertainty inherent in prognosis, and issues in the communication of prognosis to patients. Dr. Smith will discuss his work in this area, including a website for estimating prognosis for older adults (eprognosis.org and ePrognosis: Cancer Screening, available for free in iTunes).

dec-11-bbagJoin us for Alexander Smith’s lecture on Thursday, December 11, 2014 from noon till 1 pm in person or online.

Alexander K. Smith, MD, MS, MPH, is an Associate Professor of Medicine at the University of California, San Francisco (UCSF). Dr. Smith’s clinical training is in palliative medicine and general internal medicine, and his research interests are at the intersection of bioethics, palliative care, and aging. Dr. Smith is a Greenwall Faculty Scholar in Bioethics. In addition to writing for academic journals, Dr. Smith writes for his blog GeriPal. Dr. Smith was raised in East Lansing, Michigan, where his father, Blake Smith, taught at the College of Human Medicine, and where his mother, Margo Smith, currently works.

In person: This lecture will take place in E4 Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? All webinars are recorded! View our archive of recorded lectures (over 30 lectures and counting!).

Concussion in the NFL: A Case for Shared Decision-Making?

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series. For more information, click here.

By Karen Kelly-Blake, Ph.D.

“Football is not a contact sport, it’s a collision sport.”  Vince Lombardi

This is probably football’s most famous quote coming from one of football’s most iconic figures. Football, American football, is indeed a collision sport of spectacular proportion, and there lies the rub.

Broncos Texans Football
Photo: © Eric Lars Bakke/Denver Broncos

The National Football League (NFL) is being sued by more than 4000 former players charging that the NFL failed to inform them of the harm of playing with concussions, and that the NFL “… Ignored, minimized, disputed, and actively suppressed broader awareness of the link between sub-concussive and concussive injuries in football and the chronic neuro-cognitive damage, illnesses, and decline suffered by former players.” (Breslow 2014)

Former players with repetitive brain trauma are now being diagnosed with a neurodegenerative disease known as “chronic traumatic encephalopathy.” (Testoni et al. 2013) The NFL admits that in-game concussions occur about 100 times a year, but teams report only half this number. (Lipsky 2008) Football is about hard hits, and the harder the more exciting, so the question is not whether there is risk of concussion in playing football, but whether the players are fully and properly advised about the risk.

Stiggelbout et al. (2012) have argued that shared decision-making (SDM) is an ethical imperative that incorporates the four principles of medical ethics: respecting autonomy, beneficence, non-maleficence, and justice. The SDM model focuses on patient and provider sharing information and making a decision together. The provider provides information about treatment alternatives, risks and benefits, and the patient provides information about his preferences, and what is important to him for living his best possible healthy life. This model is about collaboration where both parties negotiate and agree with the decision. The model makes the assumption that the clinician is able to objectively tap their clinical expertise and that the patient can effectively identify and assess their own values relevant to the respective clinical decision and understand and appreciate the evidence. (Bogdan-Lovis and Kelly-Blake 2013) Often adding to the complexity and potential confusion surrounding SDM is the disagreement over interpretation of the available evidence, presentation of the relevant information, patient rights and responsibilities, and physician rights and responsibilities, which all work to confuse the interaction. (Bogdan-Lovis and Kelly-Blake 2013)

Traditionally, SDM has focused on preference-sensitive decisions where the treatment options are relatively the same as far as risks and benefits (e.g. early stage prostate cancer treatment, colorectal cancer screening, mammography), and so the choice depends on patient preference. Concussion is not preference-sensitive, but should that rule it out as an area for collaborative decision making? No, because SDM is an opportunity to engage in meaningful communication, most typically, in the clinical encounter.

Photo by Andy Lyons/Getty Images
Photo by Andy Lyons/Getty Images

However there are areas of concern. First, the typical patient-doctor dyad does not exist in the NFL. The health care relationship in the NFL is a triad—team, team doctor, and player. Second, a typical SDM conversation would occur during a routine clinical encounter, but when would the SDM conversation occur between player and team doctor? On the sideline after the player has been hit, and the team doctor is trying to diagnose if he even has a concussion, or the next day when his head is hurting and his ears are ringing, and he is just thankful that he was able to get out of bed? Probably not, but maybe, a SDM conversation can occur prior to signing a contract because players undergo extensive physicals before signing a team contract. This could offer an opportunity to communicate that identification of concussion is not straightforward and that there are short- medium- and long-term consequences of sustaining head trauma, and if a concussion occurs, explain the treatment options. And lastly, are the doctors making determinations about concussion trained to do so, i.e. neurologists? Pellman, former head of the NFL Committee on Mild Traumatic Brain Injury was a rheumalogist! (Lipsky 2008; Pellman 2006)

I would argue that players fully apprised of the risks of concussion and how it should be treated would err on the side of caution and delay return to play until they are clinically able to do so. Of course, with the “just win, baby” mentality of the NFL, and dare I say, the fans, this position may appear grossly naïve. The conversation would need to occur using plain language, i.e.  “You have a diagnosed concussion, you need to sit out for the next three weeks, and if you don’t, and sustain additional head trauma, you may not be able to tie your shoes, shave, or recognize your children in 20 years.” Both the team doctor and player would benefit from having such a “real discussion” in that the doctor can remember that even though the team is his employer that his priority has to be the best interest of the player/patient, and the player/patient has to be forthcoming in reporting symptoms.

The team is heavily invested in winning, the team doctor is invested in the success of the team by which he is employed and in the health of the player (hope reigns supreme here), and the player is invested in keeping his contract. There are a number of conflicts embroiled in this triad. Shared decision-making, touted as ethically imperative for patient-centered care may be one way to make sure players and team doctors can achieve a care relationship that ensures the best interest of the player/patient in both the short- and long-term.

Disclosure statement: I am an avid football fan. Some have argued that fans bear some of the blame for the disregard of player health related to concussions. We can consider that for future discussion.

References:

Bogdan-Lovis E, Kelly-Blake K. Autonomy’s Child: Exploring the Warp and Woof of Shared Decision Making (paper presented to the American Society for Bioethics and Humanities Annual Meeting, October 24-27, 2013, Atlanta, GA).

Breslow JM. NFL Concussions: The 2013-14 Season In Review. Frontline. Jan 30, 2014. http://www.pbs.org/wgbh/pages/frontline/sports/concussion-watch/nfl-concussions-the-2013-14-season-in-review/

Fainaru S, Barr J. New questions about NFL doctor. ESPN.com. Aug 18, 2013. http://espn.go.com/new-york/story/_/id/9561661/central-figure-nfl-concussion-crisis-appointed-years-ago-league-position-commissioner-paul-tagliabue-patient

Jenkins S, Maese R. NFL medical standards, practices are different than almost anywhere else. The Washington Post. March 16, 2013. http://wapo.st/Z6tOqs

Lipsky B. Dealing with the NFL’s Concussion Problems of Yesterday, Today, and Tomorrow. Fordham Intellectual Property, Media & Entertainment Law Journal. Mar 12 2008;18(4):959-996. http://ir.lawnet.fordham.edu/iplj/vol18/iss4/3

Pellman E, Viano D. Concussion in professional football: summary of the research conducted by the National Football League’s Committee on Mild Traumatic Brain Injury. Neurosurgical Focus. Oct 15 2006;21(4). http://www.medscape.com/viewarticle/553967

Stiggelbout AM, Weijden T Van der, De Wit MPT, Frosch D, Légaré F, Montori VM et al. Shared decision making: really putting patients at the centre of healthcare. BMJ. Jan 27 2012;344:e256 DOI: http://dx.doi.org/10.1136/bmj.e256

Testoni D, Hornik CP, Smith PB, Benjamin Jr. DK, McKinney Jr. RE. Sports Medicine and Ethics. The American Journal of Bioethics. Sep 11 2013;13(10):4-12. DOI: 10.1080/15265161.2013.828114, http://dx.doi.org/10.1080/15265161.2013.828114

list-cropKaren Kelly-Blake, Ph.D., is a Research Associate in the Center for Ethics and Humanities in the Life Sciences at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, August 7, 2014. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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Michigan State Medical Society’s 16th Annual Conference on Bioethics to feature Leonard Fleck

Leonard Fleck, Professor in the Center for Ethics and the Department of Philosophy at MSU, will be speaking at the 16th Annual Conference on Bioethics, hosted by the Michigan State Medical Society September 21-22 at the Campus Inn in Ann Arbor, Michigan.

The conference, Will the Patient-Physician Relationship Survive? will explore the growing threats to the doctor-patient relationship subsequent to ongoing economic, political, regulatory, and technological transformations in health care.

Dr. Fleck’s lecture, Parsimonious Care: Does Ockham’s Laser Belong in Medicine’s Black Bag? will take place on the second day of the conference.

For more information or to register, visit the Michigan State Medical Society’s website.

Brownbag & Webinar Series welcomes Larry Churchill

Larry R. Churchill, PhD, is the Ann Geddes Stahlman Professor of Medical Ethics at Vanderbilt University, where he works with the Ethics Consult Serve and teaches medical students and residents. One of his nagging preoccupations is the adequacy of moral theorizing for the human situation. He is most at home, ethically, with David Hume and the late Roman Stoics. His most recent book is Healers: Extraordinary Clinicians at Work, with David Schenck (Oxford, 2012). His book What Patients Teach: The Everyday Ethics of Healthcare is—he hopes—nearing completion.

Everyday Ethics: What Clinicians and Patients Say about Relationships and Why They Work

Since its inception, the field of bioethics has favored a principle-oriented approach, circling around a familiar triumvirate of autonomy, beneficence and justice. Yet in the routine encounters between clinicians and patients these principles, understood as action guides, play only a minor role. Relational capacities and the quality of clinical interactions are far more important aspects of medical and healthcare ethics. This talk presents results from 105 clinician and patient interviews focused on the morally important features of therapeutic relationships. I will argue that what is needed for sound bioethics and professional ethics is less application of principles and more appreciation of the rhythms of vulnerability and responsiveness.

Join us for Dr. Churchill’s lecture on Tuesday, September 25, 2012 from noon till 1 pm in person or online:

In person: The lecture will take place in East Fee Hall on MSU’s East Lansing campus, in the Patenge Room (C102). Directions. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

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