The power of a shared decision-making approach in the field of ophthalmology: will what is written in the medical and lay press work for my patient?

O poder da decisão compartilhada em oftalmologia: o que está escrito nos artigos científicos e da imprensa funciona nos meus pacientes?

Eduardo M Rocha Monica Alves Rosália M. S Antunes-Foschini Wanderley Marques Bernardo About the authors

In March 1996, several new eye drops entered the market. During his fellowship, one of the authors of this editorial had just finished preparing a prescription for a patient. He listed six medications, with the precise dosage for each, and envisioned the patient safely making it through to follow-up four months later. He was very proud of having matched a clinical diagnosis to the patient's presenting complaint, understood its mechanisms, and recommended treatment with efficacy supported by the medical literature. Before his final talk with the patient, he stopped to confirm his plan with his supervisor. The simple question from this senior doctor was never forgotten: How will this patient, whose corrected vision is counting fingers, who lives by herself and who has several other limitations and prescriptions, be able to follow your recommendations?

The young doctor returned to the patient with a simpler prescription, more modest goals, and a more frequent follow-up schedule. He has been trying to not forget that lesson since then. The lesson relates nowadays to a movement in medicine called "shared decision-making," which is defined as an approach for treatment or screening that is decided with the patient after an informed discussion with the doctor who communicates the harms and benefits of a course of action and takes the patient's preferences into consideration11 Blair L, Legare F. Is shared decision making a utopian dream or an achievable goal? Patient. 2015;8(6):471-6.,22 Agoritsas T, Heen AF, Brandt L, Alonso-Coello P, Kristiansen A, Akl EA, et al. Decision aids that really promote shared decision making: the pace quickens. BMJ. 2015; 350:g7624.. Studies call this movement "a public imperative." Including the patient in the decision-making process aims to promote a more open, respectful, and transparent medical practice. In addition, it is hoped that it will reduce the influence of the marketing of medical procedures and treatments by advertising that is taking the place of evidence-based decisions, a recent topic of interest in both the medical and the lay press33 Angell M. The truth about drug companies. New York: Random House; 2004. 319 p.

4 Welch HG, Schwartz LM, Woloshin S. Over-diagnosed. Boston: Beacon Press; 2011. 229 p.
-55 Elwyn G, Fisher E. Higher integrity health care: evidence-based shared decision making. Circ Cardiovasc Qual Outcomes. 2014;7(6):975-80..

Including the patient's views in the medical decision is not new, although it is probably now being applied to more informed, demanding, and empowered patients. In 1992, Emanuel and Emanuel classified the doctor-patient relationship as paternalistic, informative, interpretive, and deliberative, a spectrum in which the last two types are closer to the shared decision-making approach66 Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA. 1992;267(16):2221-6. Comment in: JAMA. 1992;268(11):1410-1; author reply 1412-3.. Several examples were given where the treatment was tailored according to the patient's decision, cultural and economic background, professional activity, and historical context.

In the field of ophthalmology, there are a number of opportunities for including patients in the shared decision-making process. Patients want to be involved, and we must be ready. This is particularly important in light of frequently asked questions: "When should I go for cataract surgery?" "Are contact lenses possible at my age?" "Is that type of anesthesia or re-operation the best option?" "Is this frequency of visits or exams really necessary or safe?" These are just a few examples of the questions we encounter in everyday practice. Indeed, this is particularly important nowadays as patients have easy access to a lot more information, which can be either good or bad.

Recent reports in the literature have revealed that the shared decision-making approach improves the doctor-patient relationship and compliance, reduces medical malpractice litigation, and potentially saves money for both patients and health care providers11 Blair L, Legare F. Is shared decision making a utopian dream or an achievable goal? Patient. 2015;8(6):471-6.,77 Hoffmann TC, Del Mar C. Patients' expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med. 2015;175(2):274-86. Comment in: Lakartidningen. 2015;112. JAMA Intern Med. 2015;175(2):287-8.

8 Durand MA, Moulton B, Cockle E, Mann M, Elwyn G. Can shared decision-making reduce medical malpractice litigation? A systematic review. BMC Health Serv Res. 2015; 15:167.
-99 Oshima Lee E, Emanuel EJ. Shared decision making to improve care and reduce costs. N Engl J Med. 2013;368(1):6-8.. This last observation is based on the idea that the shared decision-making approach works well in contrast to the so-called defensive medicine model, where more diagnostic tests and treatments are ordered without discussion with the patient to provide legal protection for the doctor. On the other hand, this model has been questioned in the literature as possibly being more expensive and time-consuming, but also because it may induce patient insecurity11 Blair L, Legare F. Is shared decision making a utopian dream or an achievable goal? Patient. 2015;8(6):471-6.,77 Hoffmann TC, Del Mar C. Patients' expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med. 2015;175(2):274-86. Comment in: Lakartidningen. 2015;112. JAMA Intern Med. 2015;175(2):287-8.,1010 Durand MA, Carpenter L, Dolan H, Bravo P, Mann M, Bunn F, et al. Do interventions designed to support shared decision-making reduce health inequalities? A systematic review and meta-analysis. PLoS One. 2014;9(4):e94670.. The latter concern is that patients may simply be left on their own to decide on a treatment or procedure. Other excuses or barriers to applying shared-decision have been noted. "I already do it." "My patients do not understand enough or do not want to share the decision." "I cannot use this approach in vulnerable patients." These and other myths about shared-decision making have been addressed by Légaré and Thompson-Leduc1111 Legaré F, Thompson-Leduc P. Twelve myths about shared decision making. Patient Educ Couns. 2014;96(3):281-6..

Ophthalmology is a field ripe with opportunities for research on improvements in practice and outcomes using the shared decision-making approach. The current medical models of clinical research are difficult to apply in predicting any particular patient's outcome when so many different drugs and surgical techniques are available. To overcome that difficulty, several groups in other specialties have proposed methods to help doctors supply patients with consistent and accessible information to assist in decision-making 1212 Coylewright M, Shepel K, Leblanc A, Pencille L, Hess E, Shah N, et al. Shared decision making in patients with stable coronary artery disease: PCI choice. PLoS One. 2012; 7(11):e49827.,1313 Elwyn G, Pickles T, Edwards A, Kinsey K, Brain K, Newcombe RG, et al. Supporting shared decision making using an Option Grid for osteoarthritis of the knee in an interface musculoskeletal clinic: A stepped wedge trial. Patient Educ Couns. 2016;99(4):571-7.. Similar approaches would be useful, for instance, in glaucoma, where more than fifty thousand treatment options have been rather facetiously described, frequent changes in treatment are a predictor of a worse outcome, and factors related to noncompliance are rarely taken into consideration1414 Realini T, Fechtner RD. 56,000 ways to treat glaucoma. Ophthalmology. 2002;109(11): 1955-6.

15 Oliveira DF, Lira RP, Lupinacci AP, Paccola M, Arieta CE. Cataract surgery complications as a cause of visual impairment in a population aged 50 and over. Cad Saude Publica. 2008;24(10):2440-4.

16 Paula JS, Ramos Filho JA, Cecchetti DF, Nagatsuyu DT, Rodrigues M de L, Rocha EM. Medical decision, persistence of initial treatment, and glaucoma progression in a Brazilian reference hospital. Arq Bras Oftalmol. 2010;73(2):141-5.
-1717 Silva LR, de Paula JS, Rocha EM, Rodrigues M de L. [Factors related to glaucoma treatment compliance: patients' opinions from a University Hospital]. Arq Bras Oftalmol. 2010;73(2):116-9. Portuguese.. Also, it is possible that we could offer better options for the outliers who do not respond to treatment according to the guidelines and who want precision and personalized medicine1818 Jameson JL, Longo DL. Precision medicine-personalized, problematic, and promising. N Engl J Med. 2015;372(23):2229-34..

The shared medical decision-making approach in the field of ophthalmology can be a valuable tool, which needs to be used wisely, taking into consideration demography, accessibility, and financial resources available for health care. Moreover, as has recently been pointed out, this approach can help to rescue the integrity and credibility of health care55 Elwyn G, Fisher E. Higher integrity health care: evidence-based shared decision making. Circ Cardiovasc Qual Outcomes. 2014;7(6):975-80..

  • Funding: No specific financial support was available for this study.

REFERENCES

  • 1
    Blair L, Legare F. Is shared decision making a utopian dream or an achievable goal? Patient. 2015;8(6):471-6.
  • 2
    Agoritsas T, Heen AF, Brandt L, Alonso-Coello P, Kristiansen A, Akl EA, et al. Decision aids that really promote shared decision making: the pace quickens. BMJ. 2015; 350:g7624.
  • 3
    Angell M. The truth about drug companies. New York: Random House; 2004. 319 p.
  • 4
    Welch HG, Schwartz LM, Woloshin S. Over-diagnosed. Boston: Beacon Press; 2011. 229 p.
  • 5
    Elwyn G, Fisher E. Higher integrity health care: evidence-based shared decision making. Circ Cardiovasc Qual Outcomes. 2014;7(6):975-80.
  • 6
    Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA. 1992;267(16):2221-6. Comment in: JAMA. 1992;268(11):1410-1; author reply 1412-3.
  • 7
    Hoffmann TC, Del Mar C. Patients' expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med. 2015;175(2):274-86. Comment in: Lakartidningen. 2015;112. JAMA Intern Med. 2015;175(2):287-8.
  • 8
    Durand MA, Moulton B, Cockle E, Mann M, Elwyn G. Can shared decision-making reduce medical malpractice litigation? A systematic review. BMC Health Serv Res. 2015; 15:167.
  • 9
    Oshima Lee E, Emanuel EJ. Shared decision making to improve care and reduce costs. N Engl J Med. 2013;368(1):6-8.
  • 10
    Durand MA, Carpenter L, Dolan H, Bravo P, Mann M, Bunn F, et al. Do interventions designed to support shared decision-making reduce health inequalities? A systematic review and meta-analysis. PLoS One. 2014;9(4):e94670.
  • 11
    Legaré F, Thompson-Leduc P. Twelve myths about shared decision making. Patient Educ Couns. 2014;96(3):281-6.
  • 12
    Coylewright M, Shepel K, Leblanc A, Pencille L, Hess E, Shah N, et al. Shared decision making in patients with stable coronary artery disease: PCI choice. PLoS One. 2012; 7(11):e49827.
  • 13
    Elwyn G, Pickles T, Edwards A, Kinsey K, Brain K, Newcombe RG, et al. Supporting shared decision making using an Option Grid for osteoarthritis of the knee in an interface musculoskeletal clinic: A stepped wedge trial. Patient Educ Couns. 2016;99(4):571-7.
  • 14
    Realini T, Fechtner RD. 56,000 ways to treat glaucoma. Ophthalmology. 2002;109(11): 1955-6.
  • 15
    Oliveira DF, Lira RP, Lupinacci AP, Paccola M, Arieta CE. Cataract surgery complications as a cause of visual impairment in a population aged 50 and over. Cad Saude Publica. 2008;24(10):2440-4.
  • 16
    Paula JS, Ramos Filho JA, Cecchetti DF, Nagatsuyu DT, Rodrigues M de L, Rocha EM. Medical decision, persistence of initial treatment, and glaucoma progression in a Brazilian reference hospital. Arq Bras Oftalmol. 2010;73(2):141-5.
  • 17
    Silva LR, de Paula JS, Rocha EM, Rodrigues M de L. [Factors related to glaucoma treatment compliance: patients' opinions from a University Hospital]. Arq Bras Oftalmol. 2010;73(2):116-9. Portuguese.
  • 18
    Jameson JL, Longo DL. Precision medicine-personalized, problematic, and promising. N Engl J Med. 2015;372(23):2229-34.

Publication Dates

  • Publication in this collection
    Jul-Aug 2017

History

  • Received
    30 July 2017
  • Accepted
    31 July 2017
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