Case 5: The patient as a partner
Mrs. Johnson (a 44-year-old scientist) has suffered from neck pain for almost a year, due to a
herniated disc. After months of physical therapy without much improvement, the general
practitioner referred her to the orthopedist in order to assess whether an operation might offer a
solution for Mrs. Johnson.
After the physical examination, the orthopedist discussed the results with Mrs. Johnson: “Based on
the results of the physical examination, I think it is not a good idea to perform an operation. Based on
the statistics there is a chance of 50% that your complaints will decrease significantly after the
operation, but you have about the same chances to recover with a conservative treatment, so by
continuing physical therapy and doing exercises. A big advantage of the conservative treatment is
that you are not exposed to the risks of an operation. So, I recommend you choose the conservative
treatment.”
Mrs. Johnson was not satisfied with this recommendation:
“But how do you know that the chances for me are also 50/50? I am Mrs. Johnson not Mrs. Average!
It is very well possible that my odds to recover are much higher than 50% with an operation. I am in a
good physical condition and live a healthy lifestyle. Besides, I already have had physical therapy for
several months without any improvement. I expected that this hospital would offer a more
personalized approach in their care.”
Mrs. Johnson and the orthopedist discussed this issue further and the orthopedist performed some
additional assessments. Finally, they both agreed that for Mrs. Johnson an operation would be the
best option.
Three months later, after her operation, Mrs. Johnson received an evaluation form of the hospital in
which she was invited to rate her satisfaction with the care received. She also received a letter in
which the hospital asked whether she would be interested in participating in a quality improvement
process in the hospital. Mrs. Johnson was pleased with this request to play an active role in
improving the quality of care in this hospital.
Practical application (to be discussed during the post-discussion of case 5)
In 2015 Alexandra Robbins wrote the following article for The Atlantic: https://www.theatlantic.com/
health/archive/2015/04/the-problem-with-satisfied-patients/390684/ After reading the literature for
your learning goals of case 5, read Robbins’ article and critically reflect on it using the literature. Do
you consider satisfied patients a problem? How can patient satisfaction be managed to prevent it to
become a problem? Consider for example the role of measuring patient satisfaction, the use of
patient satisfaction outcomes in policy making, the roles of those involved (e.g. patient, doctor,
nurses, management, healthcare insurers), the measures for patient satisfaction, etc.
Satisfied patients are not the problem, but the reimbursement system according to patient
satisfaction is the problem. So, another reimbursement system must be applied by the hospitals.
Also, the questionnaires for patient satisfaction should be adapted to get more answers about the
care provided instead of getting answers about how happy they are.
What is shared decision making?
Shared decision making (SDM): an approach where clinicians and patients share the best available
evidence when faced with the task of making decisions, and where patients are supported to
consider options, to achieve informed preferences (Elwyn, 2012)
Important aspects of SDM
- Accepting that individual self-determination is a desirable goal
- Clinicians support patients to achieve individual self-determination wherever feasible
o Self-determination: our intrinsic tendencies to protect and preserve our well-being
- Recognizing the need to support autonomy by building good relationships, respecting both
individual competence and interdependence on others
, o Relational autonomy: the view that we are not entirely free, self-governing agents
but that our decisions will always relate to interpersonal relationships and mutual
dependencies
Barriers to SDM
- Low health literacy
- Low numeracy
- Culture (backgrounds that lack a tradition of individuals making autonomous decisions)
Why SDM
- Knowledge gain by patients
- More confidence in decisions
- More active patient involvement
- Informed patients elect for more conservative treatment options
Evidence for shared decision making (patient decision aids)
- Knowledge (options, pros, cons) becomes more
- Involvement in decision becomes more
- Preference towards decision becomes more
- Patient adherence stays the same
- Invasive treatments become less
- Health becomes more
- Anxiety/consultation length stays the same
Three-step model for clinical practice
- A simplified model that illustrates the process of moving from initial to informed preferences
- 3 key steps of SDM
o Choice talk: the step of making sure that patients know that reasonable options are
available
Step back
Offer choice
Justify choice – preferences matter
Check reaction
Defer closure
o Option talk: providing more detailed information about options
Check knowledge
List options
Describe options – explore preferences
Harms and benefits
Provide patient decision support
Summarize
o Decision talk: supporting the work of considering preferences and deciding what is
best
Focus on preferences
Elicit preferences
Move to a decision
Offer review
- Other important elements
o Deliberation: a process where patients become aware of choice, understand their
options and have the time and support to consider ‘what matters most to them’
Mrs. Johnson (a 44-year-old scientist) has suffered from neck pain for almost a year, due to a
herniated disc. After months of physical therapy without much improvement, the general
practitioner referred her to the orthopedist in order to assess whether an operation might offer a
solution for Mrs. Johnson.
After the physical examination, the orthopedist discussed the results with Mrs. Johnson: “Based on
the results of the physical examination, I think it is not a good idea to perform an operation. Based on
the statistics there is a chance of 50% that your complaints will decrease significantly after the
operation, but you have about the same chances to recover with a conservative treatment, so by
continuing physical therapy and doing exercises. A big advantage of the conservative treatment is
that you are not exposed to the risks of an operation. So, I recommend you choose the conservative
treatment.”
Mrs. Johnson was not satisfied with this recommendation:
“But how do you know that the chances for me are also 50/50? I am Mrs. Johnson not Mrs. Average!
It is very well possible that my odds to recover are much higher than 50% with an operation. I am in a
good physical condition and live a healthy lifestyle. Besides, I already have had physical therapy for
several months without any improvement. I expected that this hospital would offer a more
personalized approach in their care.”
Mrs. Johnson and the orthopedist discussed this issue further and the orthopedist performed some
additional assessments. Finally, they both agreed that for Mrs. Johnson an operation would be the
best option.
Three months later, after her operation, Mrs. Johnson received an evaluation form of the hospital in
which she was invited to rate her satisfaction with the care received. She also received a letter in
which the hospital asked whether she would be interested in participating in a quality improvement
process in the hospital. Mrs. Johnson was pleased with this request to play an active role in
improving the quality of care in this hospital.
Practical application (to be discussed during the post-discussion of case 5)
In 2015 Alexandra Robbins wrote the following article for The Atlantic: https://www.theatlantic.com/
health/archive/2015/04/the-problem-with-satisfied-patients/390684/ After reading the literature for
your learning goals of case 5, read Robbins’ article and critically reflect on it using the literature. Do
you consider satisfied patients a problem? How can patient satisfaction be managed to prevent it to
become a problem? Consider for example the role of measuring patient satisfaction, the use of
patient satisfaction outcomes in policy making, the roles of those involved (e.g. patient, doctor,
nurses, management, healthcare insurers), the measures for patient satisfaction, etc.
Satisfied patients are not the problem, but the reimbursement system according to patient
satisfaction is the problem. So, another reimbursement system must be applied by the hospitals.
Also, the questionnaires for patient satisfaction should be adapted to get more answers about the
care provided instead of getting answers about how happy they are.
What is shared decision making?
Shared decision making (SDM): an approach where clinicians and patients share the best available
evidence when faced with the task of making decisions, and where patients are supported to
consider options, to achieve informed preferences (Elwyn, 2012)
Important aspects of SDM
- Accepting that individual self-determination is a desirable goal
- Clinicians support patients to achieve individual self-determination wherever feasible
o Self-determination: our intrinsic tendencies to protect and preserve our well-being
- Recognizing the need to support autonomy by building good relationships, respecting both
individual competence and interdependence on others
, o Relational autonomy: the view that we are not entirely free, self-governing agents
but that our decisions will always relate to interpersonal relationships and mutual
dependencies
Barriers to SDM
- Low health literacy
- Low numeracy
- Culture (backgrounds that lack a tradition of individuals making autonomous decisions)
Why SDM
- Knowledge gain by patients
- More confidence in decisions
- More active patient involvement
- Informed patients elect for more conservative treatment options
Evidence for shared decision making (patient decision aids)
- Knowledge (options, pros, cons) becomes more
- Involvement in decision becomes more
- Preference towards decision becomes more
- Patient adherence stays the same
- Invasive treatments become less
- Health becomes more
- Anxiety/consultation length stays the same
Three-step model for clinical practice
- A simplified model that illustrates the process of moving from initial to informed preferences
- 3 key steps of SDM
o Choice talk: the step of making sure that patients know that reasonable options are
available
Step back
Offer choice
Justify choice – preferences matter
Check reaction
Defer closure
o Option talk: providing more detailed information about options
Check knowledge
List options
Describe options – explore preferences
Harms and benefits
Provide patient decision support
Summarize
o Decision talk: supporting the work of considering preferences and deciding what is
best
Focus on preferences
Elicit preferences
Move to a decision
Offer review
- Other important elements
o Deliberation: a process where patients become aware of choice, understand their
options and have the time and support to consider ‘what matters most to them’
