Shared Decision Skills Training from a UK Perspective

Richard Thomson Professor of Epidemiology and Public Health

Associate Dean for Patient and Public Engagement Decision Making and Organisation of Care Research Programme

Institute of Health and Society Newcastle upon Tyne Medical School

Content

•  Background and context

•  Learning from implementation work (MAGIC)

– An implementation bundle

•  Education and training

– CPD

– Undergraduate medical education

•  Conclusions and next steps

Modelsofclinicaldecisionmakingintheconsulta3on

Paternalis*c InformedChoiceSharedDecisionMaking

Patient well informed (Knowledge)

Knows what’s important to them (Values elicited)

Decision consistent with values

SDM is an approach where clinicians and patients make decisions together using the best available evidence. (Elwyn et al. BMJ 2010)

Hoffmann,T.C.,etal.(2014)."Theconnectionbetweenevidence -basedmedicineandshareddecisionmaking."JAMA312(13):1295-1296.

SDMispartofmuchwiderperson-centredcare

“Shall I have a knee

replacement?”

“Shall I have a prostate

operation?”

“Shall I take a statin tablet for the

rest of my life?”

“Should I use insulin or an alternative?”

“I would like to lose weight”

“I would like to eat/smoke/drink less”

SpectrumofSDMtoSSM

TOO

LS

SKILLS

Involvingpeopleintheircare

HourswithHCP

=4hoursinayear

Self-management

=8756hoursinayear

Systematic review of links between patient experience and clinical safety and effectiveness

•  55 studies •  Consistent positive associations between patient

experience –  Patient safety and clinical effectiveness. –  Self-rated and objectively measured health outcomes –  Adherence to recommended clinical practice and medication –  Preventive care (such as health-promoting behaviour, use of screening

services and immunisation) –  Resource use (such as hospitalisation, length of stay and primary-care

visits).

•  Some evidence of association between patient experience and technical quality of care and adverse events. Doyle, C., et al. (2013). "A systematic review of evidence on the links between

patient experience and clinical safety and effectiveness." BMJ Open DOI 10.1136/bmjopen-2012-001570

Cochrane Review of Patient Decision Aids(O’Connor et al 2014): Improve knowledge More accurate risk perceptions Feeling better informed and clear about values More active involvement Fewer undecided after PDA More patients achieving decisions that were informed and consistent with their values Reduced rates of: major elective invasive surgery in favour of conservative options; PSA screening; menopausal hormones

Improves adherence to medication (Joosten, 2008 and more)

Better outcomes in supported self-management (SSM)/long term care

“No decisions in the face of avoidable ignorance”

Reduce unwarranted variation

SDM – why should we do it?

Sowhyaren’twedoingit?• Multiple barriers

- “We’re doing it already” - “It’s too difficult” (time

constraints) - Lack of applicability - Accessible knowledge - Skills & Experience - Decision support for patients / professionals - Fit into clinical systems and

pathways Lack of implementation strategy

Légaré F, Ratté S, Gravel K, Graham ID. Barriers and facilitators to implementing shared decision-making in clinical practice: Update of a systematic review of health professionals’ perceptions. Patient Education and Counseling. 2008;73(3):526-35

Doyoudiscussthealterna3vesurgicalapproacheswithyourpa3ents?

No.Tobeperfectlyhonest,mostpa3entsarejusttoostupidtounderstandthechoice.

Newcastle Richard Thomson

Cardiff Glyn Elwyn/Maureen Fallon

Acknowledgements: The Health Foundation, Cardiff and Vale Health Board, Newcastle upon Tyne Hospitals NHS Foundation Trust, staff and patients involved across both sites.

KeylearningfromtheMAGICprogramme:an

implementa*onbundle.

Implementa3onbundle•  Interac3veshareddecisionmakingskillsdevelopment

•  AccesstodecisionsupportincludingbriefSDMtools

•  Pa3entac3va3onandprepara3on•  Measurement•  Collabora3veandfacilitatedapproach•  Organisa3onbuy-in/seniorlevelsupport•  Structuralconsidera3ons–widercontext

AccesstodecisionsupportincludingbriefSDMtools

Evidence-based decision support

• Timely and appropriate access for clinicians and patients

• Value of brief in-consultation tools (Option Grids and Brief Decision Aids)

• Fit to clinical pathways – Adapt pathway or tools? (VBAC, BPH)

T r e a t m e n t option

Benefits Risks or Consequences

Intrauterinesystem(IUS)InvolvesaminorproceduredoneintheGPprac3ce/sexualhealthclinic.MajorityofwomensaythatthefiNngissimilartomoderateperioddiscomfort

Bloodlossisnormallyreducedbyabout90%About25inevery100womenwillhavenoperiodsat1yearItlastsfiveyearsbutcanberemovedatanystage.ItismoreoVenconsideredifthetreatmentiswantedforlongerthanayear.Itusuallyreducesperiodpain.Itisaneffec3vecontracep3ve.(seeseparateleaflet)

Bleedingcanbecomemoreunpredictableespeciallyinthefirst3-6months.Thisusually,butnotalways,se]lesdownAtthe3meoffiNng,anIUSmayrarelybeplacedthroughthewalloftheuterus(about1in1000fiNngs).IUSfallsout53mesinevery1003mesitisputin.(thisisusuallyobviousatthe3me)

Treatment option

Benefits Risks or Consequences

Watchfulwai*ng-noac*vetreatment

Nosideeffectsorhospitaltreatment–canchooseanotherop3onatany3me.Yourperiodswilleventuallydisappear–averageageofmenopauseis51.

Itisalreadyhavinganimpactonyourlifeandwellbeing.Itispossiblethatperiodswillgetworserunninguptothemenopause

LumpectomywithRadiotherapy

Mastectomy

Whichsurgeryisbestforlongtermsurvival?

Thereisnodifferencebetweensurgeryop3ons.

Thereisnodifferencebetweensurgeryop3ons.

Whatarethechancesofcancercomingback?

Breastcancerwillcomebackinthebreastinabout10in100womeninthe10yearsaVeralumpectomy.

Breastcancerwillcomebackintheareaofthescarinabout5in100womeninthe10yearsaVeramastectomy.

Whatisremoved? Thecancerlumpisremovedwithamarginof3ssue. Thewholebreastisremoved.

WillIneedmorethanoneopera*on

Possibly,ifcancercellsremaininthebreastaVerthelumpectomy.Thiscanoccurinupto5in100women.

No,unlessyouchoosebreastreconstruc3on.

Howlongwillittaketorecover?

Mostwomenarehome24hoursaVersurgery

Mostwomenspendafewnightsinhospital.

WillIneedradiotherapy? Yes,forupto6weeksaVersurgery.

Unlikely,radiotherapyisnotrou3neaVermastectomy.

WillIneedtohavemylymphglandsremoved?

Someorallofthelymphglandsinthearmpitareusuallyremoved.

Someorallofthelymphglandsinthearmpitareusuallyremoved.

WillIneedchemotherapy?

Yes,youmaybeofferedchemotherapyaswell,usuallygivenaVersurgeryandbeforeradiotherapy.

Yes,youmaybeofferedchemotherapyaswell,usuallygivenaVersurgeryandbeforeradiotherapy.

WillIlosemyhair? HairlossiscommonaVerchemotherapy.

HairlossiscommonaVerchemotherapy.

Op3onGrid

Pa*entac*va*onandprepara*on

A6flyerforuseinappointmentleTers,wai*ngareas,consul*ngrooms.Postersforuseinwai*ngareasandconsul*ngrooms.Shortfilmtoencouragepa*entinvolvement:‘SoJustAsk’

“Patient activation”

Acknowledgement to Shepherd et al, School of Public Health, University of Sydney

Measurement

Measurementandrapidfeedback

• Measurement for monitoring, research or QI?

• Align with wider QI activity

• Patient experience data a challenge •  Validity, reliability, social acceptability bias

•  Role of measures that inform practice

Collabora*veandfacilitatedapproach

Clinicalteamengagement

• Leadership and champions

•  Team of champions (including non-clinical)

• Opportunities for shared learning e.g. learning sets, clinical leads’ meetings

•  Importance of medical leadership & role of nurse specialists

• Different facilitators for different teams

•  Keeping SDM on the agenda of the team

•  Patient experience – decision quality

•  Support new developments (place of birth)

•  Support for model of delivery (MDT in head and neck cancer)

•  Practice payments

•  Peer pressure/CCG and national initiatives (1000 lives)

Organisa*onbuy-in/seniorlevelsupport

Leadership•  Walk-arounds(clinic/wardvisits)byExecu3veBoardmembers

•  InternalBoardreportsiden3fyingshareddecisionmakingasanorganisa3onalpriority

•  GrandRoundspresentedbyseniorclinicians•  DedicatedExecu3veBoardmemberworkingwithimplementa3onteam

•  “Boardchecklist”•  Pa3ent/laymemberrole

Structuralconsidera*ons–widercontext

Widerpolicyandsystemsissues•  SDM is a part of the wider drive for person-centred care •  SDM needs to be incentivised within the system (e.g. key metrics/

performance management; national/ professional body support; commissioner and board buy in)

•  Tensions exist –  Rapid progress through cancer care pathways; QOF; tendering

processes within the English market; criterion based models of referral management and NICE guidance

•  Need for national coordination around education and training •  Coordination nationally between patient experience/SDM and LTC/

SSM •  Access to resources at the time needed – e.g. within info systems •  Use of routine data for monitoring and QI •  Research needed (e.g. NIHR) to develop valid and reliable

measurement of SDM

SouthTynesideCCG•  SDMkeycomponentofReferralImprovementScheme(RIS)in2012/13

•  Pressuresaroundelec3veac3vitypar3cularlyOPinGeneralSurgery,OrthopaedicsandGynaecology

•  Trainedstaffacrossall28prac3ces

•  Be]ermanagementofpa3entswiththesecondi3ons–moreconfidentGPswithmoresa3sfiedpa3ents(ques3onnaire)

•  Financialsavingsofaround£500kin1stOPa]endances•  Engagementwithsecondarycaretoadoptsimilarprac3ce–

earlystageinvolvementintop3ps/BDAdevelopmentetc.

SharedDecisionMaking

Educa3onandTraining

GPMAGICChampions

Pa3entempowerment

RISscheme

DirectPrac3ceSupport

DevelopmentofKeyresources–TopTips/BDAs

Keylearning:Summary •  SDM is so much more than tools; more to do with skills and new ways

of consulting (aided by decision support) – different conversations

•  Complex PDAs have a role, but also need simpler in-consultation support (Option Grids/Brief Decision Aids).

•  Need to embed within clinical pathways (or adapt) and show value to clinicians

•  Important emerging role of patient activation (provided service is ready to respond)

• Measurement of patient experience hard at local level, but local measures likely to be of value if they stimulate change and inform clinical practice (e.g. DQM)

•  Importance of leadership

• Wider context

Interac*veshareddecisionmakingskillsdevelopment

Acknowledgements

Dave Tomson GP Lead MAGIC Newcastle

Glyn Elwyn Dartmouth

Elsa Randles Senior Medical Tutor, Newcastle

Clinicalskillsdevelopment•  Cornerstone of implementation and a real success of the MAGIC programme •  Skills trump tools, but attitudes trump all •  Interactive, advanced skills-based training is core •  Eye opening and valued – moving from “we do this already” to “I think we do

this, but we could do it better” •  What is important to patient (values) is key learning

Elwyn G, Frosch D, Thomson R, et al (2012) Shared Decision Making: A Model for Clinical Practice . J Gen Int Med. 10.1007/s11606-012-2077-6

Advanced micro-skills training

•  2-3hourfacilitatedworkshop•  Upto25par3cipants• Mul3disciplinary(teams)•  Prepara3on•  Introduc3ontotheSDMconsulta3onmodel•  ANtudinalexercises•  Roleplay+/-briefdecisionaids

– Pre-preparedscenarios– Bringyourown

•  PlanforuseinclinicalseNng

Statements (1) Decide the extent to which you agree with the following statements where 1 = completely disagree and10 = completely agree

Healthcare professionals are responsible

for supporting patients to make decisions that the patient feels are best

for them, even if the professional disagrees

Statements (2) Decide the extent to which you agree with the following statements where 1 = completely disagree and10 = completely agree

Doctors shouldn’t offer their opinion on

which treatment might be best for a patient.

Learning outcomes •  GainaclearoverviewofthenatureofSharedDecisionMaking(SDM),

•  ExploreyouraNtudestoSDMandsomeofthereasonswhydoingitevenbe]ermightbeimportant

•  Understandandprac3ceanumberofcoreskillsinSDM:–  Introducingchoice,invi3ngpar3cipa3onandexploringop3ons

•  Balancegoodqualityinforma3onoftherisks,benefitsandconsequencesoftheseop3ons

•  Usedecisionsupportmaterials•  Explorewhatma]erstothepa3ent•  Howtoarriveatashareddecisionthatis‘right’forthepa3ent•  Haveabe]erideaofyournextstepsinembeddingSDMinyourownprac3ceand,whereappropriate,inyourorganisa3on.

•  .

672 trained in SDM skills (Phase I/II): 352 primary care 242 secondary care 78 in external organisations 22 trained as SDM trainers: 2 fully trained 20 have had taster session External: SDM skills in undergraduate curriculum Training hospital clinical tutors Products: 1/2/3 hour training packages Risk communication Workbook and trainers handbook

“There is an entire science/structured approach behind the letters SDM and this session opens the door and illustrates what this is all about”

“I need to ask different questions to increase shared decisions. I need to change my approach”

“I spend more time eliciting patients' personal preferences for treatment options and understanding their preferences.”

Training is the cornerstone of implementation

Key learning: training •  Cornerstone of implementation and a key success of the

MAGIC programme

•  Training workshops one of the most successful (and copied) MAGIC interventions

•  Move from actor patients to participant role play

•  Skills trump tools, but attitudes trump all – need for attitudinal exercises

•  Demonstrating the critical nature of understanding what is important to the individual patient (values).

•  Overcoming belief SDM is only about tools

•  Preferably to be part of a wider programme of implementation (small dose)

History in undergraduate medical curriculum: a story of stealth

2007 •  1hr interactive full year lecture in year 2, Public Health

stream – Patient and public involvement in health care •  2 hour small group seminar: risk interpretation exercise;

challenges of involving patients 2011 •  Integration with GP visit. Observe, reflect, discuss, talk to

patient 2013 Review of SDM throughout curriculum

Spiral curriculum 2014 onwards

•  Year 3 long term conditions and supported self management – project based

•  Year 4

•  Bridging interactive lecture introduced

•  Experiential work on clinical attachments

•  Year 5 – Preparing for Practice (skills) •  Risk communication

seminar •  Micro-skills role play

session

Year 5 skills based training

Risk communication – 1 hr interactive tutorial with exercises (eg AR v

RR) and reference to use of brief decision aids Role play

– Based on MAGIC and adapted for stage of training

– Distributed delivery across multiple sites – Training clinical tutors

Examining (2016)

•  This station assesses your ability to communicate risk effectively and to share decision making with a patient

•  Scenario: pre-surgery in-patient (night before surgery for colon cancer) admitted for blood transfusion of 4 units prior to surgery as anaemic. Gets crisis call and wishes to leave and return in the morning (livelihood threatening), but won’t get 2 units of transfusion before he leaves.

•  Actor patient.

Evaluation/Learning: Skills Tutors •  Huge variation is staff training needs •  Impact on tutor clinical practice •  Relevance to training stage? Students •  Generally positive •  “Knew this already” •  Importance understood- not questioned •  Relevance at this stage “SDM only for senior

doctors”

Challenges and Next steps •  Further development of MAGIC – Advanced skills

training –  Refining (e.g. video clips) and scaling up –  Training and supporting cadre of trainers –  Mental health setting –  Service user trainers and training for service users (MH)

•  Further development undergraduate –  Revised scenarios for relevance to junior doc –  Assessment in clinical exam (introduction 2016) –  Full curriculum review

•  National and regional work on mapping skills for 21st century clinical practice (person-centred care) across the career course

•  National coordination (Health Foundation/Health Education England, GMC etc.)