From the Classroom to the Clinic: Shared Decision Making

J. Gregory Carroll, PhD 555 Long Wharf Drive, 13 th Floor New Haven, CT Bayer Institute for Health Care Communication

Benefits of Change PatientImproved health status ClinicianIncreased satisfaction Health SystemReduced costs Family and FriendsGreater availability WorkIncreased productivity PatientImproved health status ClinicianIncreased satisfaction Health SystemReduced costs Family and FriendsGreater availability WorkIncreased productivity

Source: Prochaska & DiClemente IDENTIFICATION Stages of change CONCEPTS

People don’t adhere 30 to 40% of all patients fail to follow preventive regimens 20 to 30% of all patients fail to follow curative medication regimens 50% of all patients on long term regimens fail to adhere 50% of all patients requiring life style changes fail to adhere 30 to 40% of all patients fail to follow preventive regimens 20 to 30% of all patients fail to follow curative medication regimens 50% of all patients on long term regimens fail to adhere 50% of all patients requiring life style changes fail to adhere (Hayes et al, 1979; DiMatteo et al, 1994; Clark & Becker, 1998) CONCEPTS

Conviction Confidence Stuck: frustrated Stuck: skeptical Stuck: unaware or cynical Moving: helping High Convinced Ambivalent Helpless Powerful Low CONCEPTS

The clinician is the intervention Key elements – Ask before tell: open-ended inquiry; assess conviction and confidence – Build rapport: reflective listening, empathic communication – Tailor the method to match the patient’s conviction and confidence Key elements – Ask before tell: open-ended inquiry; assess conviction and confidence – Build rapport: reflective listening, empathic communication – Tailor the method to match the patient’s conviction and confidence CONCEPTS

Ask the patient to quantify “On a scale of 0 to 10, how important is it to you to make this change?” “On a scale of 0 to 10, how confident do you feel that you can make this change?” “On a scale of 0 to 10, how important is it to you to make this change?” “On a scale of 0 to 10, how confident do you feel that you can make this change?” TECHNIQUES

Enhancing confidence Assist the patient to: Recall times when she/he has been successful making changes Make a conscious, deliberate choice to make the change; support the patient’s autonomy Move away from an either/or frame of mind Assist the patient to: Recall times when she/he has been successful making changes Make a conscious, deliberate choice to make the change; support the patient’s autonomy Move away from an either/or frame of mind CONCEPTS

Enhancing confidence cont. Assist the patient to: Define steps that are likely to lead to success Attend to progress and to perceive slips as occasions for problem solving rather than as failure Ask the patient: “For your confidence to move from a 2 to a 4 on a scale of 10, what would have to happen?” Assist the patient to: Define steps that are likely to lead to success Attend to progress and to perceive slips as occasions for problem solving rather than as failure Ask the patient: “For your confidence to move from a 2 to a 4 on a scale of 10, what would have to happen?” CONCEPTS

Enhancing conviction Assist the patient to: Illuminate the discrepancies between goals and actions Discover the normal conflicts of values which lead to ambivalence Assist the patient to: Illuminate the discrepancies between goals and actions Discover the normal conflicts of values which lead to ambivalence Provide new information when it is relevant. Ask the patient’s permission CONCEPTS

Enhancing conviction cont. Assist the patient to: Clarify a values hierarchy Identify optional reward systems Ask the patient: “For you to become more convinced that this change is in your best interest, say from a 2 to a 4, on a scale of 0 to 10, what would have to happen?” Assist the patient to: Clarify a values hierarchy Identify optional reward systems Ask the patient: “For you to become more convinced that this change is in your best interest, say from a 2 to a 4, on a scale of 0 to 10, what would have to happen?” CONCEPTS