Dr. Erica Spatz: Shared Decision-Making
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Howie and Harlan are joined by Yale cardiologist Erica Spatz to discuss the benefits of making treatment decisions in collaboration with patients, and the challenges of shifting to a more patient-centered approach.
Harlan Krumholz: Welcome to Health & Veritas, I'm Harlan Krumholz.
Howard Forman: And I'm Howie Foreman. We are physicians and professors at Yale University. We're trying to get closer to the truth about health and healthcare. So Harlan, what's something in the news that's got your attention this week?
Harlan Krumholz: Well, what a week, Howie, to see that a kidney grown in a genetically altered pig seemed to function normally in a human being. You know, we've been talking about this field for a long time, xenotransplantation, the use of externally grown organs for human beings. But this really does represent a remarkable advance. It was done at NYU. Now, this was for a very short period of time, and there was also some real weird part about this. What they did was, they had someone who had been declared brain-dead as the host, and they did this because they were unsure what would happen and they wanted to be safe. Then some people were saying that within months, we might start seeing this more broadly, and it raises all sorts of other questions. We're going to have farms of pigs who are growing organs that are going to be prepared for humans. Well, we already have farms, so pigs who are killed for food, so for some people that shouldn't be a big deal, but for others, it may raise lots of issues about how that happened.
So anyway, big news this week, I think it's kind of exciting. It's interesting, a little scary, a little scientific-y, but we seem to be on a cusp of a change. And this is good news for the large number of people who are waiting for organs and for whom in ordinary times, like now, would be waiting for some tragedy to befall someone so that they could take advantage of healthy organs for transplant.
Howard Forman: I'm excited to hear you talk about something transformational and something that really gives us a lot of hope for the future, because I think what I wanted to talk about in the next 90 seconds is something that is just frustrating and something that we've all been aware of. And our colleague, Ted Melnick, an emergency medicine physician who you've collaborated with at Yale, did a study looking at physician turnover in a large outpatient practice and looking at features that could be gleaned from electronic health record to tell us more about why some physicians leave and some physicians stay. And I was struck by something that wasn't even a primary outcome. And that is, what many clinicians already know, and that is five and a half hours are spent charting or otherwise interacting with the electronic health record for every eight hours of scheduled patient time. And that just to me is such a striking problem at a time where patients are looking for more personal interactions, for more time with their physicians to find that so much is buried inside their bookkeeping, so to speak, their ability to bill, their ability to chart all the things that you have to do in order to practice medicine today but actually takes you away from the practice and medicine. So that's what I'm thinking about this week.
Harlan Krumholz: Yeah. I think that's part of the unintended adverse consequences that are accruing and also emblematic of the fact that these systems weren't built for usability, they weren't built in mind to try to make things easy for folks. And so I think all of our hope is that there will be a change in the way that these systems function, that if any of the consumer products, iPhones, Samsung, Amazon, or anything had adopted the approaches that are using electronic healthcare, they'd have zero customers. So it's not a satisfier.
Howard Forman: Exciting times, Harlan.
Harlan Krumholz: Some would think that, I guess.
Howard Forman: Well, it's exciting for us because we have our first guest today, and so excited that it's Erica Spatz, who you've known for a long time. I've had interactions with when she was a clinical scholar. And I'm just happy to have her here today.
Harlan Krumholz: Just for our listeners, she's one of the most amazing people I know. She's a terrific faculty member at Yale and associate professor and clinical investigator, a cardiologist, a brilliant scientist and a kind and compassionate clinician who has focused her attention quite a lot on how to strengthen the position of patients in their healthcare decision making, how to make our medical profession more humane, more sensitive, more equitable. How can we be sure that people get the outcomes that they seek? And I just want to note two really terrific pieces that she led that were published in one of the best medical journals, each one. One in 2016 called “The New Era of Informed Consent: Getting to a Reasonable-Patient Standard Through Shared Decision Making,” and another one that she wrote a year later, “Prime Time for Shared Decision Making,” also in JAMA, both introducing very innovative thinking about how we should be including patients in important decisions.
So Erica, welcome. We're so happy to have you here. You know in 2017 you said, “Prime Time for Shared Decision Making.” Is it still prime time, has anything changed? Are patients really being included in decisions to any greater extent than we have in the past?
Erica Spatz: It is always a pleasure to talk about shared decision making because it is forever a challenge. And it's not clear why we as a health system or as clinicians struggle to really bring shared decision making forward. What is shared decision making? This is a true partnership between patients and clinicians. And so we're coming together to discuss options, to understand the benefits and the trade-offs and the inconveniences of different therapies to learn more about what matters to a person, what their preferences are, what their goals are, and then to really come together to make a decision that's best for that person. And it's interesting, Harlan, because medicine in very few instances has but one best answer, but one best treatment. There's only a handful of things where we can say very strongly that there is one right way to do this and the other ways are wrong. But when people go into their doctor's office, usually they just get one recommendation, and they don't hear about the full scope of options that may be very reasonable and where they may have a strong preference for one versus another.
Howard Forman: I'm curious, Erica, about, and I know this sounds horrible, but coming from a business school, I like to ask this question: Is there a business case or even a business model to support shared decision making? Because I'm concerned that even if we prove that it is best for the patients, are health systems, are payment models encouraging this in any way?
Erica Spatz: Howie, one of the best ROIs for shared decision making is elimination of waste. And waste manifests in the healthcare system in many ways, one of which is going along with a procedure or an intervention that you never would have, had you had full understanding of all of the options available to you, including maybe not doing anything. That's one form of waste.
Another waste is lack of adherence to therapies. And when we look at why people don't adhere to medications, for example, let's take a statin medicine or even a baby aspirin. I know a baby aspirin has gotten a lot of negative press lately, but for many people with heart disease who are the majority of people that I as a cardiologist am seeing, they do need that daily aspirin. And we want them to take it every day because taking the medication every day is what's to help that person prevent heart attacks or live longer.
But adherence is so abominable, and when you talk to people about why they stopped taking a medication, many people stopped because they never really understood the value of taking it, they never really bought into this being an important medication for them. I hear so many people tell me that they forgot to pick it up from the pharmacy, they went on vacation, they forgot to bring it with them, and then they just lost track of it, which sort of means that it didn't have the value to them that we thought that was the value to us. We didn't share that value together. So I think that there's a lot of waste in the health system, a lot of missed opportunities that really stem from poor patient partnership into the care plan.
Harlan Krumholz: Yeah. I was just wondering, Erica, there's such a strong socialization in medicine for us to think about doctors at the top telling patients what to do. You know, I can remember being told that's what patients want. They want you to fill this role. You need to come in confident and just tell them and don't show any uncertainty because that'll destabilize people, and so that's what they expect from you. How was it that you started thinking that there might be another way, because you certainly must have been exposed to that same sort of strong socialization process? I mean, we come into medicine sort of open-eyed and thinking about, more about partnership. We leave thinking more about being in charge and barking out orders and what people should do. How did you resist that? What was it that turned you more toward this kind of approach?
Erica Spatz: It's a great question. And we're all indoctrinated in this culture of being the best, being the expert, knowing the literature, being able to cite that literature and then demonstrating how you're using the very best of what you know in your clinical practice. And we're constantly rewarded for knowing the results of the latest study, knowing what to recommend at the point of care. And that process I think feels good to young doctors coming out of medical school. It continues to feed itself because you become an expert in a certain area and people want your opinion on it. But where it fails is in the outcomes of your patients. Because if patients aren't on board with that, or if you're incurring negative outcomes, either because of complications of things, side effects, or even just poor patient experiences or ratings, I think we have to start to look at, well, what are we actually proving here?
And when we start to look at shared decision making and present different options, we actually need to be a lot smarter and a lot more familiar with the data to understand the limits of the data, to understand how that translates for any one individual. We talk a lot about the number needed to treat. So if I know that statins are highly effective in reducing heart disease, what does that mean for that one particular person? It means that I need to treat a hundred people like you, for example, with a statin medicine in order to see a 50% reduction. And that's how we present the data, but that doesn't really mean anything for one person.
So we really need to break that down and say, look, actually, let's look at these numbers, that your risk of having heart disease is 10%, that means 10 out of a hundred people like you are going to have a heart attack in the next 10 years. Ninety people are not going to have a heart attack. They're not, but I don't know which ten people are going to have that heart attack, so I need to treat all 100 people with a statin medicine to prevent that heart attack. And of them, not all 10 are going to have their heart attacks prevented, only a portion of them, let's say three or five out of them. So when people start to find themselves in that, “Am I more likely or less likely to have that heart attack? Am I more or less likely to benefit or to have some risks associated with therapy?,” they start to think about which groups that they belong in, and we can start to have more meaningful discussions about their lives and how they're making those decisions for themselves.
Howard Forman: So I have a lot of family members with a lot of medical problems, and one of the things that strikes me is, a lot of their encounters are, as family members will say to me, like the breeze. You go into the office. You get to say five words. The clinician tells you what to do, and they leave and you leave. And I'm wondering, what do we do as patients, as physicians, as scholars, as leaders, what can we do to move in the direction of seeing more shared decision making?
Erica Spatz: So Howie, this has been a really big challenge for the field is, how do we move shared decision making into more everyday care? I think that there's some small tips, and then I think there are bigger structural changes that can happen, and this goes back to some of the work that I did with Harlan on the informed consent. So on a small level, one of the best things that people can do is, both clinicians and patients, so it could come from either side, is to flag that a decision needs to be made. Because once we say that we are at a decision point, that means that there is more than one option. We're not just moving through some wave of, “This is the next thing that we need to do.” So flagging that there's a decision, and a patient can ask, “Do I have a decision in this? And what are the options?” Because that really opens up a lot of conversation.
And we need to train clinicians in that, because clinicians need to understand how to do that well, how to elicit people's values, their preferences, which emerge in those conversations. Very few people come to the doctor knowing what they want to do or knowing how they feel about life and risk and benefit. I mean, we need to guide those conversations so that when we are immersed talking about the information, people can identify within themselves what feels right and what doesn't, and most people can, most people have a good sense for what is best for them.
On a structural level, there are a lot of specific milestones in medicine that we could use to really leverage shared decision making. And one, as Harlan mentioned, is informed consent, because for persons having any procedure or surgery, they have to have an informed consent.
But if you look at the literature, some of the studies that we did show that those informed consents are done on the day of the surgery. And many people will tell you that they even received a first dose of anesthesia and then were asked to sign the consent form. And this is ridiculous, because this is happening for surgeries that are planned, that are elective, not urgent, so the person made the decision well ahead of time. And actually, it's cruel punishment, because the person already took the day off from work. They already fasted. They're sitting in a gown. They're cold. And now you're going to talk to them about the procedure and all the risks? I mean, most people just want to close their ears and ask, “Where do I sign?” Because nobody wants to get nervous in that way.
If we are to move the informed consent mandate that unless you opt out, this informed consent document and discussion needs to be completed prior to the day of surgery, maybe even more than a week prior to surgery, but at least not on that day. We start to move those conversations and the nitty gritties of why people might opt out of the procedure, out of the pre-op waiting room and into the office. We can also insist that these informed consent documents, which are very generic in most cases, have no information, become a more patient-centered, informed consent and can be used so that that information that you discussed doesn't just stay and live within that room, but you can record that information, or you have a video or a piece of paper to take with you out of that visit to share with your family member or another clinician on your healthcare team to have more discussions about the decision at hand.
Harlan Krumholz: You know, I was just thinking that one of the issues is that we live within the context of all of our colleagues. So here I want to give you an example and just see what kind of advice you would give me for this. So when there was a patient on the wards who had come in with a certain heart condition that left him with an option, several options actually. Could get medical therapy, potentially could get a PCI with a stent, could potentially get bypass surgery. And I thought, wow, what a great opportunity to really sit down with someone and lay out the options and understand their preferences and help them navigate through this difficult decision, and so I did that, and it took a considerable amount of time. And of course I had residents and students. I was so proud of showing them the way in which you could sort of balance risks and benefits and think about what choices and so forth.
And then the next morning the surgeon rounded and basically walked in the room and said, “You're going to die if you don't have surgery, and so really we need to sign you up for surgery. You can't really go home. We need to do it this week. What day would you like to do it?” So what would you do in that case? By the way, that surgeon wasn't intending to do anything harmful, that surgeon was doing what they thought was in the best interest of the patient and conducting themselves in the way that they had been taught. But it was sort of leading to this tension because the patient now had this concern. Here, we'd laid out all these options. The surgeon came in very confidently and said, “You need to do this.” Or, “If they were my mother, you can do whatever you want, but this seems like what you need to do this week.”
There's an issue about agreeing or disagreeing on the facts, but the styles clash. And then I think that makes it hard on patients where one person comes in and really tries to make it clear there's no one right path; you got to find the right path for you. The other one comes in and says, “Hey, I know you, I've read your chart, and this is what you need.” And it's hard to go against that.
Erica Spatz: Right. I think the scenario that you described plays out all the time, and there's only so much that we can control what somebody else says or what their orientation is. And in our healthcare system, we have so many people that are interacting with that patient. It's really hard to control the messaging. What I have shifted to, Harlan, and this really comes from some of my colleagues who are design thinkers, who are in this space seeing this play out from an outsider's perspective and seeing what could change about this so that the outcome is different. And they've really moved to much more patient empowerment and skill building that we could do with our patients to develop those skills, to be able to see that and reconcile the different opinions that they may get.
So I have tried to work with patients, in my conversations, to prepare them for what they may experience when the surgeon comes in or when they go to learn more about another procedure and then to schedule that follow-up conversation so that the person is not on the spot to make the decision right there and then but already has a plan in place to say, “This is great. I'm glad I had the conversation. I'm going to come back and make a final decision at a later time.” And it's not a perfect answer, but I think it's a reality of our healthcare system. And I think that patients are becoming more savvy to this. And I think if they can be given a few tips and preparation for what they might experience, they may be better able to understand how to process that information before the surgeon gets there.
Harlan Krumholz: Yeah. I love the idea about skills and strengthening people and not going head to head with other doctors but just letting them know that different doctors have different opinions. And that part of this is about brokering, guiding, helping, shepherding them, supporting them through a process where it's not unusual to hear disparate recommendations, but getting them back to them, thinking about, what do they need to do to align with what they think is most important, what they care most about so that the decision is right for them.
Erica Spatz: Yeah. And you know, I think that that can enhance care because I think that the perspective of a surgeon is important, and people should hear things in a different way, and something might hold true for them that didn't emerge in our conversations. And some people are very direct and go to the risks and worst possible outcomes. Other people paint a more rosy picture of the benefits but ignore the risks. And so I think it can be good to hear these different perspectives. As long as the person doesn't feel like they're lost in this process, that they have a clear way to reconcile the different information that they're hearing from different people.
Harlan Krumholz: We need to resist the temptation just to dump information on people, but we really need to help guide them through the abundance of information to figure out what's most relevant to them so they can weigh risk and benefits. And you've taught me a lot about that. I mean, you really are remarkable that way and a real gem for us to have at Yale, and I want to thank you for that.
Howard Forman: And I just want to echo that and thank you for not only sharing this with us and our listeners but also advancing the knowledge in this space, doing the hard work, and being an incredible educator of the next generation of clinicians, so that hopefully this becomes part of the culture. So, Dr. Erica Spatz, so pleased to have you as our first guest on Health & Veritas.
Erica Spatz: Thanks for having me. This was terrific.
Harlan Krumholz: Yeah, thanks Erica. You know, I received a note this week from someone who said, “I just listened to your podcast about med schools,” and they were telling me that a lot of the schools now have the CASPer exam, which is a standardized written exam with ethical dilemmas played by actors on video. And then you have five minutes to write how you would resolve the issue at hand. They went on to say that Yale hasn't adopted it, but a lot of the competency-based schools have, and that this is starting to spread it. And I thought that was quite interesting. For anyone who's listening, it's great to write us and share your perspective. I don't know, Howie, if you have anything to say about that?
Howard Forman: No, I would love the feedback as well. And I agree with the point that the school seemed to be moving in one direction, and there is some literature to support why this is more fair to the students and perhaps more helpful to making decisions, but the proof is going to be in the pudding and the outcomes, and time will tell. And I imagine that we'll see more changes in the process for medical school admissions over time.
Harlan Krumholz: Yeah, and let's have someone from the admissions committee here to join us sometime, and maybe someone from a place not Yale to join us, and we can have a little more discussion with people who are in the know and actually on the day to day.
So, we're getting to the end here, and we always like to make a sort of comment or two about either something that's keeping us up at night or that put a smile on our face. What's yours this week?
Howard Forman: Well, in keeping with our first guest and in keeping with what you just talked about, our med school, it's been a great week for Yale med school and for our students, because three of, in my mind, relatively recent former students were elected to the National Academy of Medicine, which is an incredibly high honor. Our surgeon general, Vivek Murthy, the secretary of health of the state of North Carolina, Mandy Cohen, and our own Dr. Marcella Nunez-Smith, the lead for the Biden administration COVID Health Equity Task Force, all were elected all at once. All three are incredible public servants, working hard, playing major roles in the pandemic health equity and beyond. And I'm just personally grateful that there are people like this who are so selfless with their time and willing and able to demonstrate evidence-based leadership when we really need it most.
Harlan Krumholz: Well, just to say, these people are friends of ours and people for whom we have great admiration, and I'm always amazed and impressed about the number of people at Yale who go into public service and really make a difference in the lives of people throughout the nation. It's great. And really, kudos to all three of them for getting into the National Academy of Medicine.
I guess for me, the thing this week is, I'm back to the pandemic, but this is, I think, a good thing. We're seeing about half as many new cases being reported each day as we did at the start of September, and there's I think a sense of guarded optimism that we may be going in the right direction. The vaccination rates are getting to be sort of quite high. You combine the vaccination rates with people who have been previously infected, and the effective vaccination rate is really topping out. The oldest individuals in this country are at a very high rate of having received one dose 65 and up, we’re at 96%. Amazing, remarkable.
And if we can just avoid getting a variant that evades the immunity that we've built up, we may just be able to get through this. My own personal view is, I think it's going to be with us, but I think we can be in a position where the consequence isn't any worse than a bad flu season. We still have to take care. We're going to have to probably have continuing vaccinations, but it certainly looks to be that we're on a good track right now. We're entering into, if it's a seasonality, we're entering into the winter, this is going to be the biggest challenge, but I'm hopeful that maybe the worst is over. I hate to say that out loud, but that's what my hope is.
Howard Forman: I'm hoping right alongside you.
Harlan Krumholz: You've been listening to Health & Veritas with Harlan Krumholz and Howie Foreman.
Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, you can find us on Twitter.
Harlan Krumholz: I'm @HMKYale.
Howard Forman: And I'm @thehowie.
Harlan Krumholz: Health & Veritas is produced with the Yale School of Management. Talk to you soon, Howie.
Howard Forman: Thanks very much, Harlan. Talk to you soon.