2012 Summer Medical Editors Meeting: Robert J. Volk, PhD

1. Enhancing Physician
Competencies for
Shared Decision
Making in Primary
Care
FIMDM Investigator Initiated
Grant 0143-1

2. Research Team
Principal Investigators Co-investigators
Gurjeet S. Shokar, MD
Robert J. Volk, PhD Texas Tech Health Sciences Center
MD Anderson Cancer Center
Robert J. Bulik, PhD
Navkiran Shokar, MD Barbara G. Ferrell, PhD
Texas Tech Health Sciences Center University of Texas Medical Branch
Viola Leal, BA
Consultant Suzanne K. Linder, PhD
MD Anderson Cancer Center
Patricia Dolan Mullen, DrPH
University of Texas Health Sciences Center
at Houston

3. Background
• Patients generally want to be involved in
decision making about their health.
• SDM is occurring to a very limited extent in
routine primary care practice.
• Emerging evidence supports effectiveness of
training programs in SDM skills.
• Web-based cases have been shown to be
effective in medical education.

4. Project Aims
1. Identify skills physicians need to develop, and
key behaviors they should exhibit, for
promoting shared decision making with their
patients.
2. Develop a web-based educational curriculum
using Design A Case (DAC©) software to
improve physician competencies for shared
decision making in routine practice.
3. Implement and evaluate the educational
program in a sample of primary care
physicians.

5. Aim 1
Identifying Competencies for
SDM

6. Methods for identifying sources
1. Contact leaders in SDM training (Legare,
O’Connor, etc).
2. Literature search for training
programs, conceptual frameworks,
and measurement systems.
3. Search conference presentations /
abstracts (ISDM ’09, SIIPC ’08).

7. Selected sources for generating SDM
competencies
Coding Systems Frameworks
• IDM-18 (Braddock) • CDC IDM definition (Briss)
• DSAT (O’Connor) • Competencies for IDM (Towle)
• DAS-O (Butow) • Integrative Model of SDM
• OPTION (Elwyn) (Makoul)
• Shared Treatment Model
(Charles)
Training Programs
• Peer coaching (Gattelari)
• DECISION+ (Legare)
• ODST (Ottawa)
• Train-the-Trainer (Harter)

8. Sorting of competencies into key
behaviors, themes, and steps
Unique competency
statements identified 199
Similar statements
reworded to form key 62
behaviors
Key behaviors sorted
into 21 themes 21
17 themes sequenced
into 6 steps + 4 17 4
overarching themes

9. Six Steps in the Shared Decision Making Process
1. Describe the 4. Determine 5. Negotiate a
2. Review the 3. Explore 6. Make Plans
Need for a Patient's Course of
Options Patient's Values for Follow-Up
Decision Preferred Role Action
Help undecided
patients access
Assess the Assess the
Describe the Discuss the additional support
Discuss the patient's preferred patient’s
health issue or patient’s views of and other
options. role in making the readiness to make
decision. the options. resources to
decision. a decision.
make the
decision.
Provide a
Make a plan to
balanced Elicit the patient's
Communicate Explore the review the
explanation of the initial preferences
uncertainty. patient's values. decision or
pros and cons of for the options.
deferment.
each option.
Document in the
If the patient medical record that
Provide
prefers, provide a a discussion about
Emphasize the probabilities
recommendation the problem
need for a using accepted occurred, whether a
about which
decision. principles of risk patient decision aid
option seems best
communication. was used, and what
for the patient.
decision was made.
Negotiate with the
Assess the
patient a mutually
patient’s
agreed upon
comprehension.
course of action.
Provide guidance Establish a
Overarching Encourage patient
in the decision
Tailor information
partnership with
Themes questions. to the patient.
making process. the patient.

10. Aim 2 – Develop the Case
PSA as a case model – ugh!

11. Web-based Case Learning:
Design A Case (DAC©)
• Interactive, web-based
authoring tool
– Simulates clinical setting
using standardized linear
format
– Case-based learning
– Critical reasoning skills and
reflective thinking
• Used with clerkship students
• Over 50 peer-reviewed cases
in library
• Associated with improved
Board scores

12. Case development process
Team Case Peer Peer Pilot testing
training story- Review by Review by with
in DAC© boarding SDM / DAC© physicians
PCS education-
• content • content
experts* al expert
• sequence • usability
• flow • relevance
• features
Major redesign
* New step for this project.

13. Peer review feedback and pilot testing
√ Presentation
√ Bigger font size, less text, more visuals (slides, graphics)
√ Sequencing
√ Place elements (steps) up front - visual
√ Content
√ Add module on decision aids
√ Hyperlink to key sources in IDM / SDM literature
e.g., Braddock et al, IDM-18; Barry et al, J Law Med Ethics.
√ Hyperlink to key resources / tools
√ Relevance
√ Would not select this case for CME – suggested it be offered as ethics
CME

14. Case features

15. Case demonstration
www.designacase.org

17. Case - Elements of SDM

18. Case – Faculty response feature

19. Case – Linked sources and clinical
pearls features

20. Aim 3 - Evaluation strategy
• Email invitation from NRN to membership
(snowball effect)
• Interested members received email
instructions with unique password
• Case completed - online
• Link to evaluation form (SurveyMonkey)
• Separate link to reimbursement form

21. Evaluation framework
Reaction / Learning Behavior / Results /
satisfaction application outcomes
• Rating • Knowledge • Intention to
objectives of SDM perform
• Case steps & DAs SDM
structure • Confidence behaviors
/features in SDM
Kirkpatrick & Hawk. Evaluation framework for learning. June 2006.

22. Who participated (n=49)
• Specialty • Affiliated with an
– Family medicine academic center
79.6% 55.1%
– Internal medicine
4.1% • Currently in a
– Nurse practitioner residency program
2.0% 24.5%
– Other clinicians
14.3% • Length of time in
practice
• Male (53.1%)* – Mean, 17.2 y
– Range, 4 to 35 y
* 1 participant did not indicate gender.

23. Ratings of the Case
Completed all modules 100% Length about right 82%
Case met objectives 98% Used links to other info 63%
Help understand SDM 96% Links helpful 90%
Not relevant to practice 4%
Well organized 98%
Recommend to others 84%

24. General knowledge of SDM
(% correct)
SDM is a process between patient and provider in
which both parties express values and participate 83.7
in making a decision.
The clinician alone is best equipped to make the
final decision.* 100.0
An equipoise decision is one where the scientific
evidence does not favor one option over another. 95.6
* Correct response is false.

25. Correct identification of steps in
SDM process (% correct)
Describe need for a decision. 95.2
Describe options. 100.0
Described one best option to the patient.* 93.9
Explore the patient’s values. 100.0
Determine the patient’s preferred role. 95.9
Negotiate a course of action. 91.8
Make plans for follow-up. 100.0
* Not a step in SDM process.

26. Overall confidence in performing SDM
69.4
70
60
50
% 40 30.6
30
20
10
0
0
Very confident Somewhat confident Not very confident

27. “Very Confident” in performing
SDM steps
Percent

28. Intention to perform SDM behaviors
(for PC screening)
Percent

29. Conclusions
• A case-based, online, interactive educational
program on SDM skills is well-received by
primary care clinicians.
• Knowledge of SDM processes demonstrated.
• Clinicians appear confident in performing steps
of SDM (lowest for role preferences and values).
• Some suggestion that clinicians plan to utilize
SDM processes with their patients.

30. Remaining questions
1. Are there better case models?
2. Assessing preferred role and patients’ values remains
a challenge – modeling / video?
3. Is a “single infusion” sufficient to promote SDM
behaviors? Unlikely.
Might the case be part of a multicomponent training program,
within a longitudinal experience?
4. Is ethics CME the way to go for broad dissemination?

31. Thank you
Questions

32. Additional findings related to
patient decision aids

33. Knowledge of Patient Decision Aids
Decision aids… % correct
help patients understand their options. 97.9
help patients understand the harms and benefits of the
98.0
options.
help people think about choices. 98.0
provide information about options. 98.0
help people to deliberate. 77.6
support people to forecast how they might feel. 61.2
help the process of constructing preferences. 85.7

34. Knowledge of Outcomes for Patients
who Receive Decision Aids
Patients who receive decision aids … % correct
tend to be less involved with their care.* 95.9
tend to become more anxious about their choices.* 85.7
tend to be clearer about what choice is best for them. 89.8
* Correct response was false.

35. Before this Case, were you aware of
patient decision aids?
100
90
80
70
60
%
50
40
30
20
10
0
yes no unsure

36. Do you currently use patient
decision aids in your practice?
100
90
80
70
60
%
50
40
30
20
10
0
yes no unsure

37. Do you think patient decision aids
are helpful in practice?
100
90
80
70
60
%
50
40
30
20
10
0
yes no unsure