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Reviews: Review Article

Shared Decision-making in Orthopaedic Surgery

Wilson, Charlie Dee MD; Probe, Robert A. MD

Author Information

From the Department of Orthopedic Surgery, Baylor Scott & White Health, Temple, TX.

Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Wilson and Dr. Probe.

Journal of the American Academy of Orthopaedic Surgeons: December 1, 2020 - Volume 28 - Issue 23 - p e1032-e1041
doi: 10.5435/JAAOS-D-20-00556
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Abstract

Shared decision-making (SDM) is the fundamental idea that decisions should be shared with patients, rather than made for them.1 One of the earliest mentions of shared decision-making (SDM) occurs in the report Making Healthcare Decisions, commissioned by President Jimmy Carter in 1979 to study the ethical problems in medicine. The report concluded that “SDM is the appropriate ideal for patient-professional relationships.”2 There has since been an expanding body of literature that has further defined SDM and looked at the concept's utility in clinical practice. The definition of SDM originated from ethicist literature describing four patient-physician relationship models3 and has evolved to sit in the middle of a continuum between two opposing models of medical decision-making: the paternalistic and the informed models.4,5 In the paternalistic model, the physician, as the professional in the relationship, makes clinical decisions for the patient. In the informed model, the physician's role is to educate the patient and then leave the decision-making task solely to the patient. SDM attempts to blend these two models, such that a two-way exchange of information exists in which the physician, an expert in the evidence, educates the patient on risks, benefits, and alternatives to treatment and the patient, an expert in themselves, educates the physician on their values and preferences so that the two parties can come to a mutually agreed-on decision.4,6 SDM thus produces the ideal that “variation in treatment would match variation in the patient values and minimize variation that arises from misinformation and misconceptions, poor evidence, access to care, unclear indications, or provider bias.”7

While SDM is a process of communication between physician and patient, a “decision aid” is a tool used to facilitate that process.5 The objective of this article is to provide an overview of SDM and ways to successfully incorporate it into orthopaedic practice. We will start by exploring the benefits of SDM and outline the steps involved in its practice. We will then look at indications for SDM, barriers to its implementation, and suggest strategies for gaining practical experience with SDM and decision aids. We will conclude by examining the evolving trends in SDM facilitated by advances in technology and discuss the future impact of SDM on orthopaedic practice.

Benefits of Shared Decision-making

Most patients prefer to share decision-making with their physician rather than take on a completely passive or autonomous role.8,9 SDM ushers patients into an exchange of information that fosters a sense of empowerment in the decision-making process.10 This is important because surgeons poorly predict patient treatment preferences.11 As an example, patients with trigger finger desire more orthotic use and less surgical intervention relative to their surgeons.12 The goal of SDM is to create a mutual exchange of information such that the physician has a more complete grasp on the patient's preferences.

This exchange of information results in a variety of benefits. SDM, often via the use of decision aids, reduces decisional conflict (ie, uncertainty over which course of action to take) and increases patient knowledge.13 In a systematic review of 105 studies including over 30,000 patients across multiple medical specialties, Stacey et al14 concluded that decision aids increase patient knowledge and accuracy of risk perceptions while reducing decisional conflicts related to feeling uninformed, indecision about personal values, and the proportion of people who are passive in decision-making. They also conclude that decision aids may improve value-congruent choices. Qualitative studies align with this large body of data because orthopaedic surgeons have found that decision aids enhance patient knowledge and engagement and lead to more nuanced, productive conversations with patients.15

SDM increases patient satisfaction. In an observational study of 543 patients with orthopaedic conditions, patients who were well informed and received the treatment that aligned with their individual preferences had better health outcomes and higher satisfaction.16

SDM may reduce cost, often by facilitating the union of resource utilization with true patient preferences. That is, SDM helps insure that more patients who truly desire an intervention (and less of those who do not) undergo that intervention, which typically results in fewer procedures.17 However, we would caution the reader against viewing SDM as a means of primarily reducing cost and healthcare utilization. The core principle of SDM is to consider to the needs of the patient. Indeed, “the practice of SDM helps medical professionals realign themselves with patients' informed preferences and, in so doing, place patients, not making or saving money, at the center of care.”1

Models of Shared Decision-making in Clinical Practice

Although many orthopaedic surgeons may have loose familiarity with SDM, understanding each of the unique components is crucial to fully adopt SDM into practice. Several ostensibly different models for engaging in SDM have been described1,18-21 (Table 1). Although differing in the number of defined steps, these models all contain the same core elements. First, the physician must extend an invitation for the patient to engage in the decision-making process. Many patients may have become accustomed to physicians adopting a paternalistic approach and hesitate to disrupt what they feel to be an established dynamic.22 The physician should take time to assure that the patient endorses his or her role as a partner in decision-making. After this initial step, the physician does several things, either discretely or in a blended fashion as follows: lay out the treatment options, including evidence-based risks and benefits of each, and elicit the patient's individual treatment goals and preferences. It is at this step when decision aids may be incorporated because they can help a physician describe options and determine preferences.

Table 1 - Models of Shared Decision-making
Model No. of Steps List of Steps
Three-talk model (originally described in 2012, updated in 2017)1,18 3 1. Team talk: “Work together, describe choices, offer support, and ask about goals.”
2. Option talk: “Discuss alternatives using risk communication principles.”
3. Decision talk: “Get to informed preferences and make preference-based decisions.”
SHARE19 5 1. Seek your patient's participation
2. Help your patient explore and compare treatment options
3. Assess your patient's values and preferences
4. Reach a decision with your patient
5. Evaluate your patient's decision
IMDF: six steps of shared decision making20 6 1. Invite the patient to participate
2. Present options
3. Provide information on benefits and risk
4. Assist the patient in evaluating options based on their goals and concerns
5. Facilitate deliberation and decision-making
6. Assist with implementation
Alteration to three-talk model21 4 1. The physician informs the patient that decision is to be made and the patient's opinion is important
2. The physician explains the options and the pros and cons of each option
3. Discussion of patient preferences and supporting of deliberation
4. Discussion of the patient's wish to make the decision, making the decision, and discussing follow-up
IMDF = Informed Medical Decisions Foundation

Next, a back-and-forth discussion ensues, after which the physician and the patient ideally select the treatment decision that best aligns with the patient's preferences. The physician then pursues the necessary steps to implement that treatment decision. Table 1 presents the sequence of steps from four prominent models of SDM.

Opportunities for Training in Shared Decision-making

Many orthopaedic surgeons lack an understanding of how to actually engage in SDM or received insufficient communication skills training in medical school and residency. Not surprisingly, orthopaedic surgeons do a poor job of comprehensively incorporating elements of SDM into discussions with patients.23 Additional training may help orthopaedic surgeons correct misconceptions and compensate for deficiencies.

Healthwise (Healthwise Inc.), a nonprofit medical education organization, has produced a free, online training course in SDM (https://imdfoundation.learnupon.com/users/sign_in). This course instructs physicians on the nature of SDM, the steps to engage in SDM, and how to effectively implement SDM. It takes about 90 minutes to complete and is highly recommended as a resource for deepened understanding and practice of SDM.

For additional education in SDM, orthopaedic surgeons may thoroughly review the literature we have cited, peruse textbooks devoted to the subject, or engage the services of professional consultants. Regardless of one's educational path, improved communication through SDM should be looked on as an acquired skill requiring practice before mastery.

The Role of Decision Aids in Shared Decision-making

Although the term “decision aid” is often closely associated with SDM, it is important to clarify that decision aids are tools used that may be used to facilitate the SDM process. Confusion on this point is understandable because most SDM research has been done using decision aids as a surrogate for SDM. Recognizing the utility of decision aids will be beneficial for the orthopedist who wishes to implement SDM into his or her practice.

Decision aids come in a variety of forms: videos, pamphlets, and web-based interfaces. It is important to differentiate decision aids from the more prevalent online brochures and procedural informational material. Structured review suggests that these offerings rarely provide information useful in option choice.24 By contrast, decision aids are designed to objectively provide patients with the risks and benefits of their treatment options. Ideally, these aids should be “evidence based, balanced, and able to meet patients' informational needs.”25 With this in mind, the International Patient Decision Aids Standards Collaboration and National Quality Forum have published criteria that should be considered when selecting aids for your practice.26,27 A listing of certified decision aids has been published by the Washington State Health Care Authority (https://www.hca.wa.gov/about-hca/healthier-washington/patient-decision-aids-pdas). The Ottawa Hospital Research Institute provides another useful compilation of decision aids for dozens of orthopaedic conditions that have objectively rated using the International Patient Decision Aids Standards Collaboration criteria (https://decisionaid.ohri.ca/azinvent.php).

Balanced presentation of information is a key component of certification because framing treatment outcomes as potential gains or avoided losses may have a dramatic effect on patient preferences.28 Information should also be presented at the appropriate reading level, assuring that the presented information corresponds to the health literacy of the target cohort. The average American reads at the eighth grade level. Material written at higher levels may not be well understood and therefore fail in its intended objective.29

Although most available decision aids focus on hip and knee osteoarthritis and lumbar spine pathologies, a number of sports, foot and ankle, and upper extremity decision aids have recently been developed (Figures 1 and 2). Advances in technology will only make it easier to create and deliver new decision aids. For clinicians who wish to create their own aids, guidance can be found using the Ottawa Patient Decision Aid Development eTraining (https://decisionaid.ohri.ca/). It is important to emphasize that for all of the benefits of decision aids, they are not meant to supplant the discussion between the physician and the patient, but enhance it.6 When used during a face-to-face encounter, decision aids are best incorporated while describing treatment options for the patient, but they may also be used to elicit patient goals and preferences (steps 2 and 3 of the Informed Medical Decisions Foundation model).20

F1
Figure 1:
Figure demonstrating the screenshots from a PATIENT + decision aid (with permission from PATIENT + Foundation, Utrecht, The Netherlands) on conservative versus surgical treatment of displaced distal radius fractures. A, General overview of distal radius fractures. B, Results and expectations for cast immobilization. C, Unbiased, evidence-based presentation of surgical complications with accompanying pictorial representations.
F2
Figure 2:
Figure demonstrating the screenshot from a Healthwise decision aid (with permission from Healthwise Inc., Boise, ID; ©2019 Healthwise, Incorporated) on surgical management of Achilles tendon ruptures. This particular section of the decision aid allows patients to reflect on their preferences by sliding bars along a Likert-type continuum.

Indications for Shared Decision-making

Studies suggest that most patients prefer to share decisions with physicians rather than take on completely autonomous or passive roles.5,8 This is particularly true with decisions that include an invasive surgical procedure as an option.9 Given that orthopaedic surgeons treat conditions that often involve such treatments among the options, it is likely that a large majority of our patients would prefer to share decision-making responsibility. Physicians may have preconceived notions about a patient's desired level of involvement based on factors such as race, age, or socioeconomic status, but studies have shown that these are unreliable predictors of patient preferences.30 Even when familiar with individual patients, physicians frequently misinterpret patient preferences.11 Therefore, SDM is most indicated for preference-sensitive decisions: that is, decisions for which more than one reasonable treatment option exists.

Not all decisions need to be shared. Patients desire little input in decisions for which medical expertise provides sound guidance, such the use of antibiotics for surgical infection prophylaxis.31 However, patients do fear being labeled as “difficult” and tend to place notable emphasis on the opinion of the physician.22 This makes the first step in SDM—the “invitation”—crucial because it empowers the patient to determine the degree to which he or she is involved in particular decisions.

Barriers to Implementation of Shared Decision-making

Given that most orthopaedic surgeons look favorably on SDM,6,32,33 it is disconcerting to note the slow adoption of SDM into practice. A number of obstacles, both real and perceived, hinder the adoption of SDM. Obstacles include: limitations in patient health literacy, a lack of understanding of cultural differences among patients, surgeon overconfidence, physician concerns about disruption of workflow, or simply a lack of familiarity with SDM among orthopaedic surgeons.

Health literacy is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”34 Lower income, advanced age, lack of insurance, and primarily speaking a language other than English are all factors associated with lower levels of health literacy.35 Limitations in health literacy create a chasm of understanding that make it difficult for orthopaedic surgeons to engage the patient in SDM. Still, patients with limited health literacy, who may constitute over 40% of some practices,35 do not want to be relegated to the sidelines of decision-making but prefer to maintain an active role.36 Decision aids, especially written at lower reading levels, may help orthopaedic surgeons bridge the chasm of understanding to their patients. Therefore, assessing health literacy using tools such as METER or Newest Vital Sign may be a helpful practice.37

Treatment disparities of cultural and ethnic minorities exist across multiple medical specialties.30 Although some cultural or ethnic groups may desire less of a role in the decision-making process, often, cultural differences actually result in patient preferences and beliefs that physicians are simply not as adept at engaging. For instance, African-American patients may be more inclined than patients of other ethnicities to incorporate religious beliefs when considering treatment options.30 Eliciting and then engaging with specific patient beliefs and preferences is at the core of the SDM process, and one in which physicians certainly have room for improvement. Decision aids may help with this issue because they have been shown to reduce disparities in resource utilization among minorities.38

Orthopaedic surgeons in particular may be reluctant to adopt SDM practices because of overconfidence. Orthopaedic surgeons tend to feel that the surgeries they perform as individuals are more successful than the broader evidence might suggest for a given procedure.33 A survey of 242 orthopaedic surgeons found that none considered themselves below-average diagnosticians and 25% considered themselves in the top 5% of surgeons.39 Overconfidence may result in less attention paid to alternative viewpoints (such as the patient's) and a belief that SDM is not really necessary. Orthopaedic surgeons also have the tendency to discount the psychosocial aspects of musculoskeletal conditions that may yield an array of patient-specific preferences for treatment. In doing so, we may experience treatment failures by assuming that psychosocial issues will resolve once we fix the technical aspects of musculoskeletal pathology.40

Orthopaedic surgeons may worry about the potentially negative impact of SDM on clinic workflow.6,32 Although high-quality SDM does tend to require more time from physicians during the patient encounter,23 no studies in the orthopaedic literature have assessed the potentially cumulative, time-saving impact of SDM on reducing patient phone calls, redundant clinic visits, conversations with unhappy patients because of unmet expectations, and cancelled surgeries. In addition, incorporating decision aids before the physician sees the patient—either previsit or during the down time before the physician enters the examination room—may actually save physicians time.41

How Might I Incorporate Shared Decision-making Into My Practice?

Although the literature espousing the benefits of SDM has increased in the past 2 decades, relatively little has been published on how to practically implement SDM into clinical workflow. Adoption of SDM will depend somewhat on the nature of each orthopaedic surgeon's practice: the opportunities, patient demographics, and resources of a small private group vary notable from a large academic institution. Nevertheless, common elements to a step-wise implementation of SDM exist, which will ultimately lead to enhanced physician-patient communication.

The first and most critical step in successfully growing SDM is developing a respected and energetic provider champion. Change is challenging and will present obstacles during incorporation of SDM. Having a provider champion who appreciates the ethical, empirical, and patient benefits of SDM will be crucial to overcome such obstacles.

This champion must decide early-on whether to restrict SDM adoption to their individual practice or to simultaneously involve a larger group. If they choose the latter path, champions should first expose the group of providers to training in SDM, such as the Healthwise modules (Healthwise Inc.) mentioned previously. In addition, champions should strengthen their affinity for the SDM communication style through experiential learning. Gaining experience with SDM may not be as practice-altering as it first seems. Orthopaedic providers are generally adept at discussions of risks and benefits of invasive procedures, and they can easily augment this foundation with an intentional focus on patient invitation into the decision process, a more robust discussion of treatment alternatives and a concerted elicitation of patient goals and preferences. Doing so will give these providers a hands-on experience of SDM benefits. The SDM champion or implementation team will likely be more successful in SDM adoption by choosing a single diagnosis to pilot. This limits the challenges that will invariably arise because of the change. Ideal diagnoses include those that involve potential decisional conflict for patients, those for which a structured decision process could improve operational efficiencies, and those for which a certified decision aid already exists.

With the project objectives and the participating providers defined, the implementation team should select performance metrics.25 As with all successful improvement projects, a predefined measure of achievement is crucial. If patient satisfaction is one of the major goals of the initiative, patient satisfaction measures such as Press Ganey's Clinic and CAHPS are well-established options.42,43 As an advantage, these measures are prevalent and accepted in the medical community. Unfortunately, they lack fidelity in teasing out the quality of decision-making. As alternatives, researchers in the field of SDM have developed and validated a number of scoring metrics including diagnosis-specific measures from the Massachusetts General Hospital Decision Sciences Center44 or decision regret and decisional conflict scales from the Ottawa Decision Aid Research Group.45 Finally, a team might choose to track resource utilization after SDM implementation, such as the percentage of patients who undergo surgery after an initial orthopaedic encounter. Although critical to identify an objective measure of success, these measures do have the potential to become obstacles to implementation; therefore, the implementation team should take steps to minimize the effort needed to incorporate such measures.

Finally, the implementation team must consider necessary modifications to clinic workflow while striving to achieve the goals of minimizing additional burdens placed on physicians and prioritizing facilitation of effective “decision talk” between the physician and the patient. These goals may be met through a variety of sequences: (1) conduct all components of the SDM process during a single visit, (2) distribute a previsit decision aid and conduct a streamlined version of SDM in the face-to-face patient encounter, and (3) conduct two visits, one to establish the diagnosis, engage in the initial steps of SDM, and provide a decision aid and the second in the near future to finish the SDM process after the patient has had time to interact with the decision aid and weigh options.

All three sequences are potentially valuable depending on the complexity of the decision and nature of one's practice. In the first sequence, the provider may establish the diagnosis, confirm the receptiveness of the patient involvement in the decision-making process, and facilitate a treatment decision, resulting in increased efficiency for the patient. A drawback is that the patient does not have much time to reflect on the information provided or their personal goals of treatment. In addition, the single visit approach introduces unpredictability into the physician's schedule.

The second sequence has the most potential for clinical efficiency by screening appointments for predelivery of decision aids that would result in greater patient knowledge at the face-to-face encounter, but depends on someone (either the surgeon, their staff, or a referring colleague) to discern the appropriateness of patients for aid distribution. Systems with electronic medical records (EMRs) shared among multiple medical specialties will have more efficient screening processes and may allow referring providers to distribute decision aids. Coordination between primary care and orthopaedic providers may be especially beneficial in large multispecialty practice groups. However, this sequence is not ideal for conditions that depend largely on physical examination for diagnosis; this sequence may also suffer for its dependence on patient self-motivation for utilization of the decision aid.

The third sequence may be more beneficial for practices that are not integrated with primary referral groups. It allows the physician to provide an explicit invitation to the patient to participate in SDM and explain the utility of the decision aid settling on a treatment and provides the patient time to prepare for the “decision talk” conversation with reflection and involvement of friends and family. The obvious drawback is that it requires two visits. A modern modification of this two-visit approach is the use of telehealth for one of the two visits, which may potentially mitigate the disadvantages of the two-visit workflow.

It is important to recognize that despite proficient planning, not all phases of SDM adoption will go smoothly. Anticipating this and factoring in frequent team meetings to identify problems early on will allow swift resolution and achievement of SDM goals. Development of incentives to encourage SDM use among team members will be beneficial. However, to prevent SDM from becoming a check-box activity, it is imperative for the champion to develop a positive culture around SDM while continuously minimizing barriers for the physicians.25

Inpatient Considerations

While less extensively studied, the inpatient setting presents opportunities to recognize benefits of SDM similar to those in the outpatient setting. Traumatologists often encounter diagnoses such as stable femoral neck fractures and mildly-displaced acetabular fractures that require patients to make the kinds of preference-sensitive decisions that would benefit from SDM. Orthopedic oncologists frequently encounter decisions surrounding end-of-life care that require patients to choose between multiple reasonable treatment options with varying levels of risk. While the urgency of acute injury and the weight of end-of-life discussions often necessitate a high level of tact and flexibility, the use of SDM has the potential to allow orthopedists to skillfully navigate difficult conversations with patients and families.

While similar to outpatient SDM in many respects, the inpatient environment presents challenges that call for modifications of the SDM process. Chronic illness and the effects of medications may prevent patients from articulating their core values. SDM must then be extended to family and friends, while respecting confidentiality and the patient's legal decision-making authority. While inpatients cannot be preemptively provided with decision aids, orthopedists may use aids which best function as an adjunct to the provider-patient discussion.46 Unfortunately, the availability of decision aids applicable to inpatient decisions lags that of elective procedures. Hopefully this current deficiency will be addressed as the practice of SDM creates demand for these tools.

Impact of Technology on Shared Decision-making

Most of the cited literature on SDM is based on the 40-minute decision aid DVDs. Advances in technology and better understanding of adult learning are changing the nature of decision aids into formats that promise greater ease of distribution and effective use.46-49 Key among this evolution is the use of “microlearning” tools, such as educational videos or interactive decision aids, that take only a few minutes to complete. The psychology of learning indicates that smaller bits of information provided over time increases retention compared with large pieces of information presented all at once.50 The ubiquity of patient smartphones and computers within the examination room offer underutilized opportunities for such microlearning sessions.

The universal adoption of EMR presents additional opportunities. Seamless access of decision aids by providers and delivery to patients through familiar portals are certain to remove adoption obstacles. Feedback to clinicians regarding patient utilization of decision aids will help optimize their use. Integration of patient-specific health data from the EMR will increase the precision and relevance of treatment outcome predictions. The ongoing collection and analysis of data from patients will help inform providers of patient preferences. Finally, the knowledge of outcome data from individual surgeons may provide decision-influencing information for patients.

Summary

Technology is almost certain to advance the future of SDM; however, it is critical to appreciate that the foundational principle of SDM is to improve communication through increased patient involvement in critical decisions. Whether this concept is advanced by an individual modifying his or her practice or the systematic incorporation of SDM throughout a clinic, numerous benefits exist to be realized by both the patient and the physician. Patients gain control through decisional involvement while physicians elevate the quality of examination room conversations and provide something that patients value. Regardless of the scale of adoption, all orthopaedic surgeons have the opportunity to improve their communication skills by application of the principles of SDM.

References

References printed in bold type are those published within the past 5 years.

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