Monday, 27 February 2017

Shared clinical decision: Dr. Montori’s lessons

If you want to understand what the shared clinical decision is and have 16 minutes to spare, don’t hesitate and watch this interview from Dr. Selma Mohammed and Dr. Victor Montori.

So often, patients have to decide between two or more options when faced with a clinical process, or simply to choose between taking statins or not taking them. Then comes the moment of "Doctor, if it were your mother, what would you do?" And, at this point, the doctor feels authorized to adopt the paternal attitude that the patient seems to demand. For this reason I consider it’s inspiring to highlight some of Dr. Montori’s lessons.

Medical interview is a matter between experts

The doctor is an expert on the pros and cons of clinical options while the patient is an expert on his own way of looking at things. If the two actors recognize each other's experience, then they just have to find a conversation environment that is productive enough to generate a reasonable solution between scientific evidence and patient values.

All people are capable of sharing decisions

There is a current belief, says Dr. Montori, who claims that the candidates for the shared clinical decision are people of high socioeconomic status, but this is just a myth. According to his own experience, the doctor's attitude is often the key to involving, even the indigent, in a process that, if performed right, will end up adjusting the medical performance to the way people live.

The shared clinical decision is not only for serious pathologies

The shared clinical decision should affect all medical activity, from the preventive (the example of the suitability of taking statins is one of the best known, see post 12/08/13) to complex or end-of-life therapy. The success lies only in knowing how to create the right climate and develop the support instruments that are appropriate to the subject and the specific environment.

Empathy and support materials

The doctor must be empathetic to capture the different ways of coping through the illness that each person has. Empathy is therefore a necessary element, but not sufficient, because in addition one has to know how to be effective, and for this there are many materials, especially on the internet that, to a greater or lesser degree, inform people about all kinds of pathologies, but as the process of shared clinical decision goes beyond, the information tools have to be useful to support the productive dialogue between the two experts.

We don’t have time

According to the efforts of Dr. Montori's team of more than ten years of developing materials to support the shared clinical decision, these instruments are demonstrating that involving the patient may involve an addition of two or three minutes to the "paternalistic" standard. Someone will think that this may be like a new office bureaucracy, but I strongly believe that the shared clinical decision is the future of medicine.

Finally, an example

In the video, Dr. Montori explains an example of a medical interview: "Mr. Jones, we have found the LDL cholesterol at 101 mg/dL and according to clinical practice guidelines you should have it at 100. Therefore I will prescribe a medicine to lower it and we'll see you in three months to confirm if the drug has worked or not". In this circumstance, the patient can only answer: "Whatever you say, doctor, you are the one who knows best". Then Mr. Jones will take the pills and return to the doctor after three months, having gone through a new control analysis. If, for example, his cholesterol has gone down, the patient will think he has benefited from the drug. But the question is: is reducing the risk of suffering a vascular problem from that drug proportionate to the risk of having to take it forever? Montori says that we now have decision aids, such as the one he shows in the video, so that people can decide to take the medication or not having a wider perspective on things than a simple laboratory figure.

In summary, in the shared clinical decision, there are two experts (the doctor brings the technique and the patient brings his own life) that together must elaborate the customized therapeutic plan, in a dialogue aiming to search for the most adequate action. 

Jordi Varela

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