Shared Decision MakingPosted June 25, 2013 by Joseph Largay, PA-C, CDE
With all the things I have to cover during my 20 minute follow-up visits with my patients with diabetes, I sometimes struggle with whether or not to interrupt as they tell me about something that, at first, seems irrelevant, at least to me.
I do, however, enjoy most of these discussions as I learn about their recent to Hawaii or some fishing trip. I do enjoy living vicariously through the lives of my patients!
It also turns out that these conversations are not necessarily as irrelevant as they first appear. In fact, they are often a critical part of the shared decision making process.
Involving Patients in Care Decisions
Shared decision making involves engaging patients in their own care. Personally I try to take this approach when prescribing a plan for my patients with diabetes. After all I think wouldn’t I like to be treated and respected in a similar manner?
Sometimes I find that patients who seem non-adherent are like that because no one has ever taken the time to ask them about their priorities or concerns. For instance they may not be willing to take medicine or check glucose at work or in public.
I see myself as a coach, trying to steer them down a path that empowers them to take control of their diabetes.
Making Conversations Happen
I generally open my visit with, “Good afternoon, do you have any questions or concerns about your diabetes?”
For the most part I do like the conversations that result—even though at first they do not seem to have any relevance to my treatment plan for them. Sometimes it is because we have known each other for ten or more years and they ask me about how my dogs are or if I have been fishing lately. I ask them where they are going on vacation or what they are growing in their gardens this year. Besides becoming a better listener, I have learned a few good tips from the local farmers!
Other times it can run the gamut from how expensive all their drugs have become to how much stress they are having this week dealing with family or job-related issues.
As I review my patients’ glucose logs, for example, they often ask me why the fasting readings are higher than when they go to bed. I explain it is due to the liver dumping glucose and explain that if we increase their metformin or basal insulin dose, it may help fix that problem. They leave happy with one less thing to worry about.
Countering Misperceptions about Treatment Options
One patient recently told that he had "kidney damage" was very concerned that this ultimately meant dialysis was just around the corner and, remembering something regarding not being able to take metformin in this situation, stopped taking it—leading, of course, to elevated glucose readings. After reviewing this patient’s labs and discussing that they indicated only Stage 3 CKD, the patient and I decided that we could continue with a lower dose of metformin, which we considered safe at this stage.
Lately I have also had to field numerous questions surrounding the controversy about whether the medicine patients are on is going to give them pancreatitis or pancreatic cancer. I find myself going into a defensive mode, angry that attorneys have television advertisements suggesting causality between the incretin class and pancreatitis or pancreatic cancer. These are alarming possibilities, though, so I can at least have empathy for someone taking one of these drugs and worrying that it could happen to them.
So I review what we do know and what we do not know. I tell them the short answer is that at this time we do not know if that is true. I like to use analogies with my patients, and so with one particular patient who I know is a NASCAR fan, I explain that it is perhaps a yellow flag, meaning we should proceed with caution, but this is not a red flag and we do not have to stop. I tell them in layman’s terms about the information at hand and explain that I still prescribe these medicines.
I also tell them the FDA has not come to any conclusions but stated, “At this time, patients should continue to take their medicine as directed until they talk to their health care professional, and health care professionals should continue to follow the prescribing recommendations in the drug labels.
In the end some patients leave more relaxed and continue on their medication, and some are too nervous about the possibility of these issues, at which point we discuss other viable options as a substitute for their drug and review the potential side effect profile for that drug. I tell them: ”The devil you know is sometimes better than the devil you don’t know.”
Allaying Anxieties About Injections
In another patient, I might review that they have had T2D for nine years now and, due to the progressive nature of diabetes, are just not making enough insulin to control their glucose. I explain that what that leaves us with is very few choices in medicines that are powerful enough to control it. After that discussion I ask them if they would be comfortable trying one shot a day of insulin if I prescribed it, explaining and showing them a demonstration of a prefilled pen, showing them how easy it is to administer a dose. Of course, I also state that with the newer pen needles the injection is virtually painless.
After about five minutes of dialogue we decide that they will add a basal insulin injection once a day at bedtime.
I ask them to continue checking their fasting glucose to see how effective this regimen will be and ask them if they would feel comfortable self-titrating the dose by adding one unit each day until their fasting glucose is about 100 mg/dl. They agree, and so we schedule a follow up visit in a few weeks.
In the end I usually realize that allowing patients to vent their frustrations was time well spent as we get around to discussing their diabetes. Not interrupting and allowing them to talk many times reveals important information by giving me a glimpse into what barriers they may be facing in day-to-day management of their diabetes.
At the end of the visit, after printing the treatment plan and instructions, I will again ask the question, “Do you have any questions or concerns about what we have talked about?”
I do find it more rewarding when both my patients and I leave the room shaking hands and smiling as together we have made a decision that hopefully will improve their lives. If you have any thoughts on how to better engage your patients in their care, please share them here.