Hello, I'm Idriss Guessous. We will now talk about shared decision making, A field which we have been working with Professor Zack Ganu from the University of Lausanne. The objectives of this video are; to introduce the concept of shared decision making, to explain how shared-decision making works, and to explain how to implement this in practice, and particularly for more informed decision in screening programs. So, now let's talk about the process of shared decision making which is of particular interest of training. It's important to note that decisions about screening rely almost always on preferences and values of the patient or participants, and we will talk about this. As was nicely said by Professor Abigail Zuber in an editorial published in 2013 in the Journal of the American Medical Association, styles of parenting and practicing medicine have followed quite a similar trajectories over the last half century. As can be seen in this diagram, we started with the paternalistic model, where the physicians decide what was best for his or her patients. And we moved to an information model, where the patients receive almost all the information and was the only one to decide. But in between these two extreme models, fits the model of shared decision making, where both physician and patients are actually partners. Indeed, shared decision making can be defined as an interactive decision-making process, accounting for both the patient and the physician, with equal and active participation based on shared information. And together, they shared the best available evidence, and patients can participate in the decision based on informed preferences. And several factors have made the process of shared decision making a necessity for patients, but also for clinician and society. For example, advances in medicine now provide several options of exams, treatments and even intervention for a given disease or even a given age. And these different choices have specific benefits and risks. Colorectal cancer screening by colonoscopy, or by investigation of actual blood in the stool is a very good example of this. Atrial fibrillation and anticoagulation is another good one. And these are example of preference sensitive care, where at least two valid alternatives are available. Also, clinicians are shifting their attention more toward the patient than the disease, an approach called Patient Centered Care, where an active engagement of the patient is key. Shared decision making is also a process that helps engage the patient to ask questions, and avoid what is often referred to as white cold silence. That is when patients avoid speaking, when in the presence of physicians, a phenomenon often encountered in clinical practice. Finally, shared decision making also helps to respect the principle of autonomy. That generally trumps the principle of beneficials. As a matter of fact, several surveys showed that in general, patients want to participate in making decisions with their clinicians, and at the very least they want to receive the information needed for the making a choice or a decision. A systematic review of the literature has shown that shared decision making increases patients' knowledge, reduces decisional conflict. It provides greater satisfaction, reduces the proportion of patients who remain undecided about their options, and it improves agreements between the medical option selected and the patients' values. This has been observed in screening, and with prostate cancer screening most specifically. In addition, shared decision making has been shown to improve patient adherence to treatment. While the value of shared decision making has been accepted, the way to implement it in clinical practice is less clear. Some models of how to do shared decision making in clinical practice have been proposed. One of them proposes the following steps. Identification of the problem, portrayal of options, give statements of equipoise, provide information in preferred format such as decision aids, check understanding and reactions. Discuss, make or defer decision, and finally make follow-up arrangements. So, basically, in shared decision making, the clinician presents the different options and describes the risks and benefits. Using this information, the patient expresses about his or her preferences and values. But as mentioned earlier, to help the patients digest the medical information, the process of shared decision making often relies on decision aids that can be in paper or electronic format. And decision aids are tools that help people participate in decision making about health care options. Decision aids are designed to encourage people to participate in decision making, provide accurate information about options and outcomes. It help people think about their values and preferences as they relate to the risks and benefits of each option, and finally it give guidance in the steps of decision making. Decision aids maybe booklets, pen and paper grids, videos, web-based or DVD or even web sites. Decision aids are particularly useful when patients have low level of health literacy. Because information is often about risks, patients need to understand the risk to make a decision. There are several recommendation to help patient understand risks. This is an example of a decision aid that explains the benefits of colorectal cancer screening. This decision aid shows on the left what happens to 100 people who do not participate in a colorectal screening program. Here, we can see two out of the 100 die has shown by the figures in red. On the right side, is what happens with training. So the blue figure represents one life saved. For example, clinicians should remind their patients that virtually all treatment options, are associated with some possibility of risks. Clinicians should also avoid explaining risk in descriptive terms such as low risks. They should also avoid percentages, but use a more natural frequency formats such as one in five people, also using a consistent denominator 40 out of a thousand, and five out of a thousand, instead of one in 25, and one in 200 is recommend. So, to conclude shared decision making is important in medicine and particularly for preference sensitive care such as training. Screening guidelines like the prostate cancer screening or even lung cancer screening guidelines require a shared decision making process. In this video, we discussed shared decision making in terms of the rationale of using it, the impact of using it, and how to implement it in practice. I hope you enjoyed this video, and that you now have a better understanding of shared decision making and it's utility for screening programs.
