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Clinical Decision Making
Lecture 6
Group and shareddecision making
Faculty of Medicine
The Hashemite University
Arwa Al Anber( MD, PhD)
Office: 1018
Group Decision Making
➢ Group problem solving puts manager in
role of facilitator and consultant.
➢ Groups can provide more input leading to
better decisions.
➢ Allows contribution of many people with
information or resources
➢ Leads to an averaging that is enhanced from
discussion, multiple perspectives, and feedback
Decision Making Techniques
1. Consensus
Consensus Strategy: every member must agree on the
decision
Everyone fully supports the decision
◦ May not totally agree
Best used for these conditions:
◦ All members are affected by the decision.
◦ Implementation of the solution requires coordination
among team members.
◦ Decision is critical, requiring full commitment by team
members.
2. Nominal group technique (NGT)
a structured group decision-making technique that involves
generating ideas individually, sharing them within the group, and
then ranking or evaluating the ideas collectively.
Example
1)Everyone writes down their ideas.
2)Each group member presents ideas.
3)Each idea discussed and evaluated by group.
4)Group votes on best idea.
3. Delphi technique:
• obtaining anonymous input from multiple experts
on a particular decision or problem. The experts'
opinions are collected, analyzed, and summarized to
reach a consensus.
• - does not require a group meeting
• Steps
1)Questionnaires distributed to group members
2)Responses summarized & distributed to group
3)Each person adjusts their answer each round taking
into consideration the responses of others
4)Process repeated until group reaches consensus
4. Statistical aggregation
Individuals are polled regarding a specific problem
and their responses are recorded
Advantage
◦ Does not require a group meeting.
◦ Obtains input from all members
Disadvantages:
◦ No opportunity to strengthen interpersonal
bonds
◦ No chance to modify input based on input from
others
5. Brainstorming
Group members meet and generate diverse ideas about the
nature, cause,
definition, or solution to a problem without regard to feasibility
or practicality.
All ideas recorded
Most effective at the beginning stage of decision making
6. Fishbone diagram (cause and effect)
Drawn after a brain storming session
Central problem written as the head of the fish
Skeleton divided into branches showing contributing causes of
different parts of the problem.
7. PMI (Plus/Minus/Implications)
Weighing the Pros and Cons of a Decision.
Steps:
1. Select a course of action from a range of options.
2. Draw a table with headings: Plus, Minus, Implications
3. Under 'Plus', write all positive results of taking the action.
4. Underneath 'Minus' write all negative effects
5. Under 'Implications' write implications and possible
outcomes of taking
the action( whether positive or negative)
PMI (Plus/Minus/Implications)
Plus Minus Implications
Paper charts 1) Doctors are used to
this method
2) All past information is
on paper
1) We might lose the
chart
2) Hard to read
handwriting of
doctor
1) There will be information
that is hard to organize
and will get lost
Electronic charts 1) Able to save unlimited
information
1) Cost of computers
2) Some doctors not
computer literate
3) Doctors will look
at computer rather
than patient
1) We would need to train
doctors how to use the system
2) It might be a hard transition
for a while
8. Six thinking hats:
Looking at decision from multiple points of
view
1. Red Hat: look at problem using intuition,
gut reaction, and emotion
2. White Hat: focus on all available data.
3. Black Hat: look at all of the bad points of
the decision
4. Yellow Hat: look at all possible benefits
of decision
5. Green Hat: develop creative solutions to
a problem
6. Blue Hat: worn by the leader of the
meeting, controls the thinking process
Example
You decide to close your office door while you are seeing a
patient. Red Hat: Feels hard to do practically
White hat: studies show higher patient satisfaction when doctor
shuts door and privacy is maintained
Black hat: takes time to shut the door
Yellow hat: doctor able to focus
Green hat: Install a device on the door that shuts the door
automatically
Blue hat: worn by leader of the discussion
9. Decision grid
Matrix for comparing multiple options when there are several criteria to
consider.
Useful with more complex decisions
10. Majority
Simple majority: more than half
2/3 majority, ¾ majority, etc.
Advantage: Simple
Disadvantage: Minority does not agree with decision
11. Truth Wins
One correct member is necessary and sufficient for a correct group
response
Occurs when one member says something that rest of group realizes is
correct
Based on new information or research
Best when only one correct solution exists
Example: Group is researching use of aspirin for prevention of MI in
young healthy patients. One group member finds a study specifically
addressing this issue.
Groupthink
Goal of everyone being in 100% agreement.
Hinders creativity
Usually leads to inferior decisions.
Individual biases still applicable to groups
Initial ideas often intensified by group discussion.
◦ results in tunnel vision
◦ prevents group from seeing contradictory evidence
Shared information between group members receives more attention than
unshared information
◦ Shared information: information known by multiple group members
Groupthink Example
1. A member of a group is seen as the smartest
person in the group so the group focuses on the
ideas of that person.
2. The first person to talk suggests one idea and half
of the meeting is focused on this one idea.
3. 10 doctors working at the same clinic meet to
discuss how to fix problems at their clinic. 3
doctors believe the biggest problem at their clinic
is the long wait times for patients. Most of the
meeting is spent discussing this problem.
Avoiding Groupthink
Appoint group members to roles that evaluate how the group decision
making occurs.
Encourage all group members to think independently and verbalize
their individual ideas.
Allow the group time to gather further data and reflect on data already
collected.
Advantages and Disadvantages of
Group Decision Making
Advantages:
◦ Generate more ideas which increases chance of higher
quality outcomes.
◦ Decision more likely to be accepted
◦ Can increases interpersonal bonds
Disadvantages:
◦ Time-consuming
◦ Can be wasteful and unproductive if not managed
effectively
◦ Can be costly
◦ Can generate conflict
Practice: Group Decision Making
As a group analyze the following problems and try to
make decisions regarding it:
Problem: how to enhance teaching and training activity at
medical
faculties?
1. Apply the different techniques learned for group
decision making.
2. What are the advantages and disadvantages of each
technique
used?
3. What decisions were made?
Shared Decision
Making
Definitions of SDM
❖ A collaborative process between patients and
healthcare professionals to make informed and
mutually agreed-upon decisions about the patient's
medical treatment or care plan.
❖ It recognizes the patient as an essential partner
in their own healthcare and involves them in the
decision-making process by providing information,
discussing treatment options, considering their
preferences, values, and beliefs, and reaching a
consensus on the best course of action.
❖Combines patient preferences with evidence-based
medicine.
❖In general: the patient and doctor are both involved
Elements of shared decision-
making
1. Information sharing: Healthcare professionals
provide patients with clear, unbiased, and evidence-
based information about their medical condition,
available treatment options, potential risks and
benefits, and expected outcomes.
2. Patient preferences and values: Patients are
encouraged to express their preferences, values, and
goals related to their health. Healthcare professionals
take these factors into account when presenting
treatment options and recommendations.
3. Discussion and deliberation: Both the patient
and the healthcare professional engage in open and
respectful discussions about the available options,
considering the potential benefits and risks of each
approach. This process helps in addressing any
concerns or uncertainties the patient may have.
Elements of shared decision-
making
4. Decision support tools: Decision support tools, such as patient
decision aids, may be utilized to enhance the patient's understanding of
the choices and potential outcomes.
5. Reaching a shared decision: The final decision is made collaboratively,
based on a synthesis of medical evidence, patient preferences, and
values. The patient's autonomy is respected, and the healthcare
professional provides guidance and expertise to assist the patient in
reaching an informed decision
Session-6-Shared-and-group-Decision-Making.pdf
What is the right answer?
A 65-year old woman comes to your clinic complaining of bloody stools
for 6 months. She is very tired. She says that she does not want any
tests done and is ready to die.
What should you do?
Options
A) Obey her wishes and send her home
B) Order blood tests and tell her she needs to get this done
C) Order a colonoscopy and tell her she needs to get this done
D) Ask her son what he wants you to do
E) Ask her why she doesn’t want to get any tests done and she is ready
to die
F) Others?
More information
You decide to ask her why she does not want to have any blood tests or
a colonoscopy. She tells you that she does not have transportation to
get to a lab. And she said that one of her friends died during a
colonoscopy.
What do you do now?
Options
A) Order blood tests and the colonoscopy and tell her to try her best
B) Brainstorm with her about possible ways she could get to the lab
C) Ask her son if he could take her to the lab
D) Explain the risks and benefits of the colonoscopy
E) Ask more questions about her friend who died
F) Others?
More information
You talk to her about the risks and benefits of a colonoscopy. You also
talk to her about the importance of the blood tests. The son says he can
drive her anywhere she needs to go. She says she is still afraid of the
colonoscopy but will think about it. She agrees to get the blood tests
done.
What do you do now?
Options
A) Insist that she really needs a colonoscopy
B) Set up a colonoscopy appointment without telling her and tell the
son to bring her to the colonoscopy without telling her she is getting it
C) Say ok, and let her do what she wants
D) Say ok, but emphasize the importance of the colonoscopy. Set up a
follow up appointment to go over the blood tests and see if she has
changed her mind about the colonoscopy.
E) Others?
Importance
Interventions have different benefits/ risks that patients value differently
◦ What was this called????
Often no single right answer
◦ Hyperthyroidism: meds vs. radiation vs. surgery
Ethical principle of patient autonomy
Legal requirement of informed consent
◦ Doctor never told me…
Evidence-based practice movement
◦ important piece of evidence missing without patient’s perspective
Importance (cont)
Patients cannot be forced to follow a lifestyle.
◦ Ex. Change diet, take a medicine, do a surgery, etc.
Preventative medicine requires patient empowerment for it to be
effective.
◦ Coming to visits and doing tests even when not sick
Patients have the right to make choices and the ability to act on them
Patient Empowerment
Definition: patient has right to make choices about their health care
Justification: patients experience the consequences of both having and
treating their illnesses
Patient must research sufficient information to fully understand their
health conditions and treatment plan
◦ How do we help them do this?
Patient says: Doctor responds
(Old model) (New model)
"I hate this
exercise
plan."
"Then try walking after
dinner every night with
your husband for 10
minutes
"What do you hate
about it? What would
help you do better at
it?"
"I don't think
I can quit
smoking."
"Smoking is the leading
cause of preventable
death ..."
Why do you think that?
What has happened in the
past when you tried to
quit? What concerns you
most when you think about
trying to quit?
I haven't
been able to
test my
blood sugar
four times a
"It's hard at first, but just
keep trying. You really
need to keep track of it."
"What is preventing
you from doing that?
Do you know what the
numbers mean?"
35
Barriers to Shared Decision
Making
Clinicians
◦ Challenge to physician autonomy
◦ Lack of training and practice
◦ Medical evidence difficult to
extract, interpret, and communicate
◦ Fear of liability
Practice
◦ Time (busy clinic)
◦ Lack of reimbursement
◦ Guidelines
Patients
◦ Not wanting to participate
◦ Variation in role preference
◦ Literacy and numeracy challenge
◦ Uneven information
Resources
◦ Practicality
◦ Availability
◦ Cost
Self Care
The ‘biopsychosocial’ model
Self care: ways people with long term
conditions deal with managing their
own health
Self care support: ways friends, care-
takers, relatives, and health systems
support (or do not support) people
with long term conditions who are
trying to provide self care
My condition
(Biological)
What I do
(Social /
Behavioural)
The way I feel
(Psychological)
Application
• People who provide the best self care are:
• Optimistic
• Determined
• Contextually informed (health information that
‘makes sense to me’)
• Confident
• Problem solvers, decision makers
• Part of good social networks
Steps:
1) Develop a partnership with the patient
2) Establish the patient’s preferences for information
3) Establish the patient’s preferences for their role in decision-making
4) Ask about and respond to patient’s ideas, concerns and expectations
5) Identify choices (including patient’s ideas) and evaluate the research
evidence in relation to the individual patient
6) Present (or direct the patient to) evidence
- taking into account points 2 and 3
7) Help patient assess impact of alternative decisions with regard to their
values and lifestyles
8) Make or negotiate a decision in partnership and resolve conflict
9) Agree upon an action plan and complete follow up arrangements
Practice Case 1
55-year man with newly diagnosed HTN.
Current BP - 180/100.
1) Together we can help solve this problem
2) Do you want to know a lot about HTN or just the basics?
3) Do you like to be involved in choosing your treatment?
4) What are your ideas about why you have HTN and how to treat it?
What concerns you? Do you have any expectations about the
treatment?
Practice Case 1 (cont)
5) We could start one or two medicines today as well as starting you on
a diet/exercise program.
6) Diet and exercise is important, but studies show that you will also
most likely need to take a medicine as well.
7) If you take medicine without changing your diet/exercise, the HTN
will likely get worse.
8) Let’s start one medicine today and also talk about how you can work
on your diet/exercise.
9) Let’s set up an appointment for 2 weeks.
Practice Case 2
45-year old woman with Diabetes. She already takes metformin and
glyburide but her blood sugar is still high.
1) This is a tough problem. We need to work together to help solve it.
2) Has anyone talked to you before about what diabetes is or how to
treat it?
3) Do you like to be involved in choosing your treatment?
4) What are your ideas about why you have DM and how best to treat
it? What concerns you? Do you have any expectations about the
treatment?
Practice Case 2 (cont)
5) We could start insulin today as well as starting you on a diet/exercise
program. Patient prefers just doing diet.
6) Diet and exercise is important, but studies show that you will also
most likely need to take insulin.
7) If you take medicine without changing your diet/exercise, the DM will
likely get worse.
8) Let’s work on your diet/exercise for one more month.
9) Let’s set up an appointment for 1 month.

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Session-6-Shared-and-group-Decision-Making.pdf

  • 1. Clinical Decision Making Lecture 6 Group and shareddecision making Faculty of Medicine The Hashemite University Arwa Al Anber( MD, PhD) Office: 1018
  • 2. Group Decision Making ➢ Group problem solving puts manager in role of facilitator and consultant. ➢ Groups can provide more input leading to better decisions. ➢ Allows contribution of many people with information or resources ➢ Leads to an averaging that is enhanced from discussion, multiple perspectives, and feedback
  • 3. Decision Making Techniques 1. Consensus Consensus Strategy: every member must agree on the decision Everyone fully supports the decision ◦ May not totally agree Best used for these conditions: ◦ All members are affected by the decision. ◦ Implementation of the solution requires coordination among team members. ◦ Decision is critical, requiring full commitment by team members.
  • 4. 2. Nominal group technique (NGT) a structured group decision-making technique that involves generating ideas individually, sharing them within the group, and then ranking or evaluating the ideas collectively. Example 1)Everyone writes down their ideas. 2)Each group member presents ideas. 3)Each idea discussed and evaluated by group. 4)Group votes on best idea.
  • 5. 3. Delphi technique: • obtaining anonymous input from multiple experts on a particular decision or problem. The experts' opinions are collected, analyzed, and summarized to reach a consensus. • - does not require a group meeting • Steps 1)Questionnaires distributed to group members 2)Responses summarized & distributed to group 3)Each person adjusts their answer each round taking into consideration the responses of others 4)Process repeated until group reaches consensus
  • 6. 4. Statistical aggregation Individuals are polled regarding a specific problem and their responses are recorded Advantage ◦ Does not require a group meeting. ◦ Obtains input from all members Disadvantages: ◦ No opportunity to strengthen interpersonal bonds ◦ No chance to modify input based on input from others
  • 7. 5. Brainstorming Group members meet and generate diverse ideas about the nature, cause, definition, or solution to a problem without regard to feasibility or practicality. All ideas recorded Most effective at the beginning stage of decision making
  • 8. 6. Fishbone diagram (cause and effect) Drawn after a brain storming session Central problem written as the head of the fish Skeleton divided into branches showing contributing causes of different parts of the problem.
  • 9. 7. PMI (Plus/Minus/Implications) Weighing the Pros and Cons of a Decision. Steps: 1. Select a course of action from a range of options. 2. Draw a table with headings: Plus, Minus, Implications 3. Under 'Plus', write all positive results of taking the action. 4. Underneath 'Minus' write all negative effects 5. Under 'Implications' write implications and possible outcomes of taking the action( whether positive or negative)
  • 10. PMI (Plus/Minus/Implications) Plus Minus Implications Paper charts 1) Doctors are used to this method 2) All past information is on paper 1) We might lose the chart 2) Hard to read handwriting of doctor 1) There will be information that is hard to organize and will get lost Electronic charts 1) Able to save unlimited information 1) Cost of computers 2) Some doctors not computer literate 3) Doctors will look at computer rather than patient 1) We would need to train doctors how to use the system 2) It might be a hard transition for a while
  • 11. 8. Six thinking hats: Looking at decision from multiple points of view 1. Red Hat: look at problem using intuition, gut reaction, and emotion 2. White Hat: focus on all available data. 3. Black Hat: look at all of the bad points of the decision 4. Yellow Hat: look at all possible benefits of decision 5. Green Hat: develop creative solutions to a problem 6. Blue Hat: worn by the leader of the meeting, controls the thinking process
  • 12. Example You decide to close your office door while you are seeing a patient. Red Hat: Feels hard to do practically White hat: studies show higher patient satisfaction when doctor shuts door and privacy is maintained Black hat: takes time to shut the door Yellow hat: doctor able to focus Green hat: Install a device on the door that shuts the door automatically Blue hat: worn by leader of the discussion
  • 13. 9. Decision grid Matrix for comparing multiple options when there are several criteria to consider. Useful with more complex decisions
  • 14. 10. Majority Simple majority: more than half 2/3 majority, ¾ majority, etc. Advantage: Simple Disadvantage: Minority does not agree with decision
  • 15. 11. Truth Wins One correct member is necessary and sufficient for a correct group response Occurs when one member says something that rest of group realizes is correct Based on new information or research Best when only one correct solution exists Example: Group is researching use of aspirin for prevention of MI in young healthy patients. One group member finds a study specifically addressing this issue.
  • 16. Groupthink Goal of everyone being in 100% agreement. Hinders creativity Usually leads to inferior decisions. Individual biases still applicable to groups Initial ideas often intensified by group discussion. ◦ results in tunnel vision ◦ prevents group from seeing contradictory evidence Shared information between group members receives more attention than unshared information ◦ Shared information: information known by multiple group members
  • 17. Groupthink Example 1. A member of a group is seen as the smartest person in the group so the group focuses on the ideas of that person. 2. The first person to talk suggests one idea and half of the meeting is focused on this one idea. 3. 10 doctors working at the same clinic meet to discuss how to fix problems at their clinic. 3 doctors believe the biggest problem at their clinic is the long wait times for patients. Most of the meeting is spent discussing this problem.
  • 18. Avoiding Groupthink Appoint group members to roles that evaluate how the group decision making occurs. Encourage all group members to think independently and verbalize their individual ideas. Allow the group time to gather further data and reflect on data already collected.
  • 19. Advantages and Disadvantages of Group Decision Making Advantages: ◦ Generate more ideas which increases chance of higher quality outcomes. ◦ Decision more likely to be accepted ◦ Can increases interpersonal bonds Disadvantages: ◦ Time-consuming ◦ Can be wasteful and unproductive if not managed effectively ◦ Can be costly ◦ Can generate conflict
  • 20. Practice: Group Decision Making As a group analyze the following problems and try to make decisions regarding it: Problem: how to enhance teaching and training activity at medical faculties? 1. Apply the different techniques learned for group decision making. 2. What are the advantages and disadvantages of each technique used? 3. What decisions were made?
  • 22. Definitions of SDM ❖ A collaborative process between patients and healthcare professionals to make informed and mutually agreed-upon decisions about the patient's medical treatment or care plan. ❖ It recognizes the patient as an essential partner in their own healthcare and involves them in the decision-making process by providing information, discussing treatment options, considering their preferences, values, and beliefs, and reaching a consensus on the best course of action. ❖Combines patient preferences with evidence-based medicine. ❖In general: the patient and doctor are both involved
  • 23. Elements of shared decision- making 1. Information sharing: Healthcare professionals provide patients with clear, unbiased, and evidence- based information about their medical condition, available treatment options, potential risks and benefits, and expected outcomes. 2. Patient preferences and values: Patients are encouraged to express their preferences, values, and goals related to their health. Healthcare professionals take these factors into account when presenting treatment options and recommendations. 3. Discussion and deliberation: Both the patient and the healthcare professional engage in open and respectful discussions about the available options, considering the potential benefits and risks of each approach. This process helps in addressing any concerns or uncertainties the patient may have.
  • 24. Elements of shared decision- making 4. Decision support tools: Decision support tools, such as patient decision aids, may be utilized to enhance the patient's understanding of the choices and potential outcomes. 5. Reaching a shared decision: The final decision is made collaboratively, based on a synthesis of medical evidence, patient preferences, and values. The patient's autonomy is respected, and the healthcare professional provides guidance and expertise to assist the patient in reaching an informed decision
  • 26. What is the right answer? A 65-year old woman comes to your clinic complaining of bloody stools for 6 months. She is very tired. She says that she does not want any tests done and is ready to die. What should you do?
  • 27. Options A) Obey her wishes and send her home B) Order blood tests and tell her she needs to get this done C) Order a colonoscopy and tell her she needs to get this done D) Ask her son what he wants you to do E) Ask her why she doesn’t want to get any tests done and she is ready to die F) Others?
  • 28. More information You decide to ask her why she does not want to have any blood tests or a colonoscopy. She tells you that she does not have transportation to get to a lab. And she said that one of her friends died during a colonoscopy. What do you do now?
  • 29. Options A) Order blood tests and the colonoscopy and tell her to try her best B) Brainstorm with her about possible ways she could get to the lab C) Ask her son if he could take her to the lab D) Explain the risks and benefits of the colonoscopy E) Ask more questions about her friend who died F) Others?
  • 30. More information You talk to her about the risks and benefits of a colonoscopy. You also talk to her about the importance of the blood tests. The son says he can drive her anywhere she needs to go. She says she is still afraid of the colonoscopy but will think about it. She agrees to get the blood tests done. What do you do now?
  • 31. Options A) Insist that she really needs a colonoscopy B) Set up a colonoscopy appointment without telling her and tell the son to bring her to the colonoscopy without telling her she is getting it C) Say ok, and let her do what she wants D) Say ok, but emphasize the importance of the colonoscopy. Set up a follow up appointment to go over the blood tests and see if she has changed her mind about the colonoscopy. E) Others?
  • 32. Importance Interventions have different benefits/ risks that patients value differently ◦ What was this called???? Often no single right answer ◦ Hyperthyroidism: meds vs. radiation vs. surgery Ethical principle of patient autonomy Legal requirement of informed consent ◦ Doctor never told me… Evidence-based practice movement ◦ important piece of evidence missing without patient’s perspective
  • 33. Importance (cont) Patients cannot be forced to follow a lifestyle. ◦ Ex. Change diet, take a medicine, do a surgery, etc. Preventative medicine requires patient empowerment for it to be effective. ◦ Coming to visits and doing tests even when not sick Patients have the right to make choices and the ability to act on them
  • 34. Patient Empowerment Definition: patient has right to make choices about their health care Justification: patients experience the consequences of both having and treating their illnesses Patient must research sufficient information to fully understand their health conditions and treatment plan ◦ How do we help them do this?
  • 35. Patient says: Doctor responds (Old model) (New model) "I hate this exercise plan." "Then try walking after dinner every night with your husband for 10 minutes "What do you hate about it? What would help you do better at it?" "I don't think I can quit smoking." "Smoking is the leading cause of preventable death ..." Why do you think that? What has happened in the past when you tried to quit? What concerns you most when you think about trying to quit? I haven't been able to test my blood sugar four times a "It's hard at first, but just keep trying. You really need to keep track of it." "What is preventing you from doing that? Do you know what the numbers mean?" 35
  • 36. Barriers to Shared Decision Making Clinicians ◦ Challenge to physician autonomy ◦ Lack of training and practice ◦ Medical evidence difficult to extract, interpret, and communicate ◦ Fear of liability Practice ◦ Time (busy clinic) ◦ Lack of reimbursement ◦ Guidelines Patients ◦ Not wanting to participate ◦ Variation in role preference ◦ Literacy and numeracy challenge ◦ Uneven information Resources ◦ Practicality ◦ Availability ◦ Cost
  • 37. Self Care The ‘biopsychosocial’ model Self care: ways people with long term conditions deal with managing their own health Self care support: ways friends, care- takers, relatives, and health systems support (or do not support) people with long term conditions who are trying to provide self care My condition (Biological) What I do (Social / Behavioural) The way I feel (Psychological)
  • 38. Application • People who provide the best self care are: • Optimistic • Determined • Contextually informed (health information that ‘makes sense to me’) • Confident • Problem solvers, decision makers • Part of good social networks
  • 39. Steps: 1) Develop a partnership with the patient 2) Establish the patient’s preferences for information 3) Establish the patient’s preferences for their role in decision-making 4) Ask about and respond to patient’s ideas, concerns and expectations 5) Identify choices (including patient’s ideas) and evaluate the research evidence in relation to the individual patient 6) Present (or direct the patient to) evidence - taking into account points 2 and 3 7) Help patient assess impact of alternative decisions with regard to their values and lifestyles 8) Make or negotiate a decision in partnership and resolve conflict 9) Agree upon an action plan and complete follow up arrangements
  • 40. Practice Case 1 55-year man with newly diagnosed HTN. Current BP - 180/100. 1) Together we can help solve this problem 2) Do you want to know a lot about HTN or just the basics? 3) Do you like to be involved in choosing your treatment? 4) What are your ideas about why you have HTN and how to treat it? What concerns you? Do you have any expectations about the treatment?
  • 41. Practice Case 1 (cont) 5) We could start one or two medicines today as well as starting you on a diet/exercise program. 6) Diet and exercise is important, but studies show that you will also most likely need to take a medicine as well. 7) If you take medicine without changing your diet/exercise, the HTN will likely get worse. 8) Let’s start one medicine today and also talk about how you can work on your diet/exercise. 9) Let’s set up an appointment for 2 weeks.
  • 42. Practice Case 2 45-year old woman with Diabetes. She already takes metformin and glyburide but her blood sugar is still high. 1) This is a tough problem. We need to work together to help solve it. 2) Has anyone talked to you before about what diabetes is or how to treat it? 3) Do you like to be involved in choosing your treatment? 4) What are your ideas about why you have DM and how best to treat it? What concerns you? Do you have any expectations about the treatment?
  • 43. Practice Case 2 (cont) 5) We could start insulin today as well as starting you on a diet/exercise program. Patient prefers just doing diet. 6) Diet and exercise is important, but studies show that you will also most likely need to take insulin. 7) If you take medicine without changing your diet/exercise, the DM will likely get worse. 8) Let’s work on your diet/exercise for one more month. 9) Let’s set up an appointment for 1 month.