Shared Decision Making…..That’s What EBM Is But I Still Don’t Have To Like It.

This week’s New England Journal of Medicine has a Perspective article on shared decision making ( Shared decision making is basically educating the patient about options and getting them to incorporate their values and preferences into making decisions. That’s what EBM is as is shown below.

EBM paradigm

My passion is teaching EBM principles and practicing it as much as possible. So you will be surprised that I am not extolling the virtues of what the authors suggest. Not that I am against it as I am not. But as I will outline below its not practical right now.

The authors point out that shared decision making is rarely being practiced.

For example, in a study of more than 1000 office visits in which more than 3500 medical decisions were made, less than 10% of decisions met the minimum standards for informed decision making. Similarly, a study showed that only 41% of Medicare patients believed that their treatment reflected their preference for palliative care over more aggressive interventions.

I wonder why? It’s simple….time and resources. I am a primary care internist. I have 20 minutes scheduled per patient. I never get that 20 minutes. My nurses eat up a lot of it. It’s not their fault. Administration has put so many stupid reminders (like doing a homelessness screen or a preferred language screen for an institution where every one that comes there has to speak English in the first place and I don’t even have interpreters) in place that they have to do that I have maybe 5 minutes left of my appointment. So am I supposed to spend the time it would take to go over the decision aids they suggest we use? I could but then there would no time for anything else and I have to tell the patient to reschedule.

Why not just have the patient review it online on their own.” Great idea! EXCEPT that less than 30% of my patients are computer literate. Also have you looked at online decision aids? Many are way too complex for my patients. “Fine…give them a print version.” Sometimes that doesn’t exist and you can’t just hand them many decision aids and expect them to understand it. “What do the green and red smiley faces mean doctor? Which one am I?”

Which all comes back to resources. “Hire a nurse to do it doctor!” Sure….where’s the money for that? I can’t charge for this service (or at least enough to pay for a patient educator trained nurse who will demand a 6 figure salary). The current payment system is broken and until its fixed and we are paid for our time we simply can’t afford to play this game. Unfortunately the authors of this article have no clue to what the trenches are like because their ivory tower is too high for them to see us little people. They don’t understand current practice and the pressures that are on us primary care docs. Maybe we should develop a decision aid for all the idiots who keep thinking up things for us to do that aren’t really practical.