One of the themes that surfaced frequently during the second (and last) day of this conference evolved around EBHC in resource constrained settings. There were some brilliant suggestions on how to overcome challenges to practicing EBHC (such as lack of internet access or lack of access to information); some thought-provoking success stories on implementation of EBHC practices in these settings; as well as the repeated emphasis that healthcare decisions should be made within the context of the health system, the available resources and the patient’s values.
The very last plenary session of the conference addressed just this: The role of the patient in healthcare decision-making. Dr Victor Montori gave an excellent presentation on Patient-centred Evidence-based Health Care. He reminded us of one of the principles that Dr Gordan Guyatt referred to yesterday: The evidence is never sufficient (which he also referred to as the “ironic principle of EBHC”). When we define EBHC, we stress that EBHC is the combination of clinical expertise, best current evidence and patient values – it is not only about the evidence. But are healthcare practitioners really paying any attention to this component of EBHC? According to Victor Montori, this is the neglected part of EBHC – all around the world.
How do healthcare professionals (HCP) characterise patient values and their unique context as individuals? Do they really know what patients are feeling? Think about the life of a healthcare professional and that of a destitute patient – there is such an enormous difference between these contexts that it would be arrogant to pretend to know what the patient values and what it is like to live in his world.
So how are healthcare decisions made?
Victor Montori described the following decision-making models:
There is the paternal model, where the HCP tells the patient what to do and hence makes the final decision – in which case there is definitely no EBP.
If you want to practice EBHC, you need to adopt another model. There is the informed model, where the HCP gives the patient all the technical information, the patient verbalises what he wants to do and the HCP provides the evidence for that choice.
There is also the clinician-as-perfect-agent model, where the HCP provides all the necessary information, asks the patient questions about his context, his values and preferences, etc. and advises the patient on what to do. This would also be regarded as EBP, since the HCP does his best to get all the information from the patient.
Shared decision-making is a fictional model (according to Victor Montori), where the HCP and the patient share information, values, pro’s, con’s and ultimately come to a consensus on what should be done. This would be EBP – if it would happen in the real world.
Ideally, there should be a dance across models, a partnership between the individual patient and the HCP – this is called empathic decision-making. In this model, the HCP evaluates the patient and assesses whether he wants to make the decision himself or not; whether there is a difference in opinions and values; and how this differs. The skill lies in the ability to distinguish between these kind of patients, to adopt the appropriate model and to get it right with most patients. It is all about creating opportunities for conversation, asking questions and engaging with the patient.
How can decisions then be made together? Victor Montori proposed a three-step approach:
Step 1: Team and choice talk – this should emphasise that the HCP and the patient are a team and that they are going to make a decision together
Step 2: Option talk – during this step, the HCP presents all the different treatment options to the patient
Step 3: Decision talk – making the decision on what treatment to follow.
The essential part lies between step 2 and 3: the deliberation phase. This is the time the patient needs (which may take a couple of days) to consider all the treatment options, the evidence (as presented by the HCP), his values, preferences and context, as well as his support system and resources. This is where decision-aids come in as very useful tools to create conversations and to illustrate risks and benefits of different treatment options. These should make use of pictures and colours, should be easy to understand and should definitely not contain jargon.
Victor Montori and his team have created a few of these decision-aids, which are freely available on the internet eg. Statin Choice (http://statinchoice.e-bm.info) or Diabetes decision aid (http://diabetesdecisionaid.mayo-clinic.net) and are based on evidence. This is thus an excellent way of incorporating clinical expertise, evidence and patient values in the decision-making process.
Do we teach our healthcare students how to dance?