Think Like a Patient: Rationale and Resources for Shared Decision-Making in Cardiology

GRAPEVINE, TX—In an era when patients have access to medical information on the internet and are generally more informed, and often overwhelmed, than before, healthcare practitioners need to do a better job at implementing shared decision-making tools, according to experts speaking today in a prevention symposium at the Society of Cardiovascular Computed Tomography annual scientific meeting.

"Shared decision-making is the way to make anything we recommend effective for our patients,” said Martha Gulati, MD (University of Arizona, Phoenix), during her presentation. Putting this idea into practice, she explained, requires both asking about what is wrong with the patient and what the patient actually cares about.

“The great news,” Gulati told TCTMD, “is we have all these new treatments, which is excellent. More options, though, take more time, and yet we're being told by our hospitals [to] see patients quickly and move on. There's a lot of pressure and burnout on the cardiologist side because they are not being able to sit and talk with their patients, and I think that changes the dynamic.”

Some discussions involve choices about whether to take a medication or not, but others are more complex, such as the decision to advance therapy or accept a fatal prognosis. “Those are very hard conversations, and they're more than a couple of minutes,” said Gulati.

In cardiology specifically, shared decision-making works best when there is more than one reasonable option, such as a screening or a treatment decision, when no one option has a clear advantage, or when the possible benefits and harms of the treatments affect patients differently, said Gulati. For example, should a patient with A-fib receive anticoagulation or left atrial appendage closure to prevent stroke?

“You would be so surprised at the kind of old-school mentality that some physicians have,” session moderator Parag Joshi, MD (UT Southwestern Medical Center, Dallas, TX), told TCTMD. “I think really empowering the patients for their own care is the best way to improve outcomes [and] adherence.”

While the concept of shared decision-making may be “kind of a no-brainer,” Joshi added that when thinking about actions he takes regarding his own health, “if I understand why I'm doing it, I'm much more likely to do it.”

As for specific resources, Gulati recommends physicians make use of the CardioSmart tools that she has collaborated on with the American College of Cardiology (ACC). These patient-friendly tools include infographics, educational events, an app, and informational TVs that clinicians can request for their offices.

Joshi added that his clinic uses mid-level providers like nurse practitioners and physician assistants to continue conversations with patients, allowing for a continued and more focused discussion. Also, he likes using the Mayo Clinic’s statin tool, which can show patients their current and future risk levels.

Patient-Physician Disconnect

While many practitioners are implementing shared decision-making techniques in their clinical practice, there seems to be a disconnect with how physicians and patients feel they are working. According to Gulati, ACC survey data from 2014-2015 show that 80% of physicians but only 45% of patients find that shared decision-making lengthens office visits. Also, 59% of physicians and 62% of patients say these tools improve in-office discussions.

Additionally, physicians report using shared decision-making more often (85%) than patients say they encounter it (67%).

Gulati said that 88% of patients with some form of heart disease report related challenges they want to discuss with their physicians, and four out of five say they actively engage in conversations with their doctors. Importantly, she noted, the hardest thing for patients and physicians to discuss are end-of-life issues.

“Medicine is becoming far less paternalistic” thanks both to patients’ desires and the fact that they are more informed, she observed. “Patients are coming in prepared, and they're actually engaged. They already have information. So once you give them a diagnosis, what do most people do? They're on the internet and Dr. Google is answering their questions.

“Because it's hard to make something on the internet that answers everything about that one patient,” physicians need tools that can help them better individualize their care, Gulati continued.

Joshi’s advice for physicians is to always think like their patients. “When you do [something] over and over again, you start to think, ‘Why am I saying the same thing again and again?’” he said. “It becomes a little redundant or monotonous.

“Taking it from our patients’ perspective, it's new to them,” Joshi continued. “They all need this time and focused discussion.”