Victor M. Montori, MD, MScKER UNIT, Mayo Clinic

Challenging myths: Empathic decision making in usual clinical settings

Decision making models

Modified from Charles C et al

Approaches Parental Clinician-as-perfect agent

Shared decision-making Informed

Direction and amount of information flow about options

Clinician Patient Clinician Patient Clinician Patient Clinician Patient

Direction of information flow about values and preferences

Clinician Patient Clinician Patient Clinician Patient Clinician Patient

Deliberation Clinician Clinician Clinician, Patient Patient

Decider Clinician Clinician Clinician, Patient Patient

Consistent with EBM principles

No when decision is not purely technical and there

are optionsYes Yes Yes

Desired clinical behavior

EMPATHIC DECISION MAKING

1.Partnership 2.Dance across models

http://kercards.e-bm.info

Wiser Choices Programat Mayo Clinic’s KER UNIT

Settings (bold = RCT)Work Setting Policy Evaluation

Statin Choice Primary + specialty care

Effective care Feasible, effective, implemented in EHR, multicenter trial

DM2 Med Choice Primary care “Technical” care Feasible, effective, multicenter trial

Aspirin Choice Primary care (group) Effective care (but changed)

Not evaluated

Depression Choice Primary care Marketing Design phase

Genomic Choice Experimental Silent Design phase

Osteoporosis Choice Primary care Effective care Feasible, effective

ICD Choice Specialty care Preference sensitive Design phase

Smoking choice Primary care Effective care Design phase

Chest Pain Choice Emergency Effective care Feasible, effective, multicenter trial

AMI Choice Hospital ward Effective care Feasible, effective, multicenter trial

Hypertension e-primary care Effective care Design phase

Rosiglitazone General Effective care Not evaluated

Prostate General (tablet) Preference sensitive Design phase

Weymiller et al. Arch Intern Med 2007

Statin Choice

Osteoporosis Choice

Montori et al, AJM 2011

Mullan et al, Arch Intern Med 2009

Diabetes Medication Choice

AMI Choice

Chest Pain Choice

ParticipantsWork Age, mean

(range)Illness Clinician

satisfaction (%)*

Incremental time investment, median

Statin Choice 65 (55-80) Chronic, asymptomatic

74% 3.8 minutes (-2.9, 10.5)

Diabetes Medication Choice

62 (40-92) Chronic asymptomatic

90% 2.5 minutes

Osteoporosis Choice

67 (51-84) Chronic asymptomatic

75% 3.0 minutes (-56, 25)

Chest Pain Choice

54 (32-76) Acute, symptomatic

64% 1.6 minutes

AMI Choice 64 (40-85) Acute, symptomatic

NA NA

* Would like to use it again with other patients considering the same decision?

Success of the decision aid

Ethical Legal

Economic Effectiveness

Knowledge transferCreates a conversation

Fit

Implementation

UnderstandableDoable

Favorable

Fit for purpose, users, setting

http://normalizationprocess.org

Statin Decision Aid

Lessons learnt

User-centered design happens in the field, takes multiple iterations and expertise.

Testing decision aids in usual clinical settings is tough: decision moments are unpredictable.

Repeated use for chronic decisions has been difficult to study in efficacy trials.

MythsGoal and settings

1. Decision aids have no role in evidence-based care2. Decision aids support shared decision making3. Valid decision aids cannot be used in busy clinical

settings, such as primary care

Participants4. Clinicians would not want to use decision aids – they are

barriers to adoption of SDM5. Acutely ill patients are not good targets for SDM6. Elderly chronically ill patients cannot participate in SDM

Summary of 5 years of work

13 wiser choices decision aidsChronic and acute care

Primary and specialty careRural, urban, and academic

50+ sites200+ clinicians600+ patients

In trials!

http://kerunit.e-bm.orghttp://kercards.e-bm.infohttp://shareddecisions.mayoclinic.org

montori.victor@mayo.edu

@vmontori