Want to cut down on the number of non-critical chest pain patients that you admit into the ER? You do, admit it. Sanjay and Mike discuss how showing them a card with some pretty pictures on it might be win win win win for everyone.
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NICE STUDY, BUT NOT A BIG FAN OF SHARED DECISION MAKING. THIS WAS STILL 58% OF PATIENTS WHO DID NOT NEED ADMISSION BASED ON BEST EVIDENCE. WE ARE THE ONE WHO WENT TO MEDICAL SCHOOL AND DID A RESIDENCY, AND WE SHOULD DECIDE WHO TO ADMIT AND WHO TO SEND HOME. LET'S STOP WORRYING ABOUT LAWSUITS AND PRACTICE EVIDENCED BASED AND COST EFFICIENT MEDICINE.
Totally agree with above comments. If one ever wanted to know why "joint decision" making is a bad idea, they should listen to this segment. All those admissions, all those costs....completely unwarranted. We have sent those low risk chest pain patients home for 20 years; never have seen a missed MI, never had an argument with a patient a patient about going home. Would I ask a patient who had a sprained ankle if they wanted to be admitted? I just don't get it. Patients come to us for an opinion. I think we should give them one: "you do not need to be admitted!"
I believe that joint decision making is best employed when we have several reasonable options available for good patient care, not when the diagnosis and treatment are obvious. I have found that patients appreciate being involved in the decision making process when appropriate. This does not mean that we always do just as the patient requests: if the patient does not need an antibiotic, I do not give him one.
Mel, I could not find a link enabling me to see the decision tool, card, itself. Did I miss it in the notes? I used the link to the abstract, but there was no way to access the card that I could find.
The key to shared-decision making (SDM) is that it is only used when there are 2 or more reasonable and appropriate management options. In other words, there must be clinical equipoise for SDM to be applicable. If a patient with chest pain is very low risk, so low risk that virtually no emergency physician would admit them, then there is no clinical equipoise and thus SDM should not be used.
I believe there are many ED clinical scenarios where SDM is appropriate, although some of these are debatable and will vary from doc to doc. One example is immediate CT head vs. ED observation for minor pediatric blunt head trauma. I will often explain the harms and benefits of both options to the parents and help them decide what they prefer...but only when there is clinical equipoise i.e it is unclear whether the kid would benefit from a CT scan. If the kid is extremely high risk or extremely low-risk, then I make the decision.
As Jacques states above, most patients (and parents) really appreciate being explained the options and being involved in the decision. Better patient rapport can lead to improved patient satisfaction scores and decreased medico-legal risk. Win-win for everyone.
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Derek I., M.D. - January 8, 2014 1:44 AM
NICE STUDY, BUT NOT A BIG FAN OF SHARED DECISION MAKING. THIS WAS STILL 58% OF PATIENTS WHO DID NOT NEED ADMISSION BASED ON BEST EVIDENCE. WE ARE THE ONE WHO WENT TO MEDICAL SCHOOL AND DID A RESIDENCY, AND WE SHOULD DECIDE WHO TO ADMIT AND WHO TO SEND HOME. LET'S STOP WORRYING ABOUT LAWSUITS AND PRACTICE EVIDENCED BASED AND COST EFFICIENT MEDICINE.
Barry N. - January 13, 2014 3:26 PM
Totally agree with above comments. If one ever wanted to know why "joint decision" making is a bad idea, they should listen to this segment. All those admissions, all those costs....completely unwarranted. We have sent those low risk chest pain patients home for 20 years; never have seen a missed MI, never had an argument with a patient a patient about going home. Would I ask a patient who had a sprained ankle if they wanted to be admitted? I just don't get it. Patients come to us for an opinion. I think we should give them one: "you do not need to be admitted!"
Jacques R. P. - January 22, 2014 12:10 PM
I believe that joint decision making is best employed when we have several reasonable options available for good patient care, not when the diagnosis and treatment are obvious. I have found that patients appreciate being involved in the decision making process when appropriate. This does not mean that we always do just as the patient requests: if the patient does not need an antibiotic, I do not give him one.
Mel, I could not find a link enabling me to see the decision tool, card, itself. Did I miss it in the notes? I used the link to the abstract, but there was no way to access the card that I could find.
Marc P. - February 7, 2014 3:32 PM
The key to shared-decision making (SDM) is that it is only used when there are 2 or more reasonable and appropriate management options. In other words, there must be clinical equipoise for SDM to be applicable. If a patient with chest pain is very low risk, so low risk that virtually no emergency physician would admit them, then there is no clinical equipoise and thus SDM should not be used.
I believe there are many ED clinical scenarios where SDM is appropriate, although some of these are debatable and will vary from doc to doc. One example is immediate CT head vs. ED observation for minor pediatric blunt head trauma. I will often explain the harms and benefits of both options to the parents and help them decide what they prefer...but only when there is clinical equipoise i.e it is unclear whether the kid would benefit from a CT scan. If the kid is extremely high risk or extremely low-risk, then I make the decision.
As Jacques states above, most patients (and parents) really appreciate being explained the options and being involved in the decision. Better patient rapport can lead to improved patient satisfaction scores and decreased medico-legal risk. Win-win for everyone.