Shared Decision-Making

Quality and Novel Delivery Models

We talked extensively about informed consent, and a key question was raised: “if true informed consent and shared-decision making occurs between providers and patients, will that reduce revenue?”

Although the question on this is a difficult one to answer, my thought is to say no. Along those same lines, Dave Mayer also commented that one group, particularly at MedStar Health, that has been on the forefront of improving processes has been Orthopedic Surgery. They have realized the paramount need to reduce variation in their practice patterns. As they say: No outcome, no income.

I wanted to comment particularly about a growing model of delivering care to patients, particularly with complex and semi-elective surgeries. This particular model is called Employers Centers of Excellence Network (ECEN). It basically is a form of value-based purchasing in which large companies such as Lowe’s, McKesson, Wal-Mart participate. If one of their employees needs a procedure… Continue reading

The black box and improving informed consent

This was another educational and emotional day for me at the Telluride QI/PS summer camp. The first part of the day was focused on informed consent and shared decision making. I was moved to tears watching the story of Michael Skolnik and am so thankful to his parents for sharing their story with us.

It really got me thinking about the appropriate use of the informed consent document and how poorly we often counsel and consent our patients for complex and dangerous procedures.

In Michael’s case we will never know what transpired between him and the surgeon on the day he was consented for that second procedure. But Michael is not the first nor will he be the last patient who cannot tell us whether he received and understood all the necessary information to make an appropriate decision about such an invasive procedure.

Should we as physicians be relying on… Continue reading

“We should stay here. Tonight.”

I thought it would be hard to compete with the great experiences of day one in Telluride, but day two did not disappoint. We spent a couple hours today focusing on “Strategic Negotiations” with Paul Levy. We participated in a few exercises, and despite my nerves going into it, I was pleasantly surprised with my performance. (Although I did have to pay $10 on a bid for a $10 bill that I actually didn’t even win.)

Levy discussed many interesting topics, including tactics for how to make the best deal. I quickly realized that although negotiations seem very businesslike on the outside, the true heart of the matter comes down to reading the vibes of the other party and trying to gauge where they stand. To put it in Harvard Business School/Levy terms, you need to figure out what your BATNA is, or your Best Alternative To a Negotiation… Continue reading

“If We Could See Inside Others’ Hearts”

Today was the first official day of the Academy for Emerging Leaders in Patient Safety: The Telluride Experience, and after just a few short hours here I realized how fitting that name is. First of all, Telluride really is an experience. The beauty can’t be captured in pictures and the peacefulness and tranquility is something that can only be felt. It truly is the perfect location to forget about the stress of life and the pressure of school and focus on the important issue of patient safety. Second, the insight, opinions, and ideas that my fellow “Telluride Alumni” have already shared makes me believe that these really are the emerging leaders in patient safety. The discussions had during day one have already exceeded my expectations and I look forward to what the rest of the week will bring.

One of the topics that came up today that resonated with me… Continue reading

Sharing difficult stories

We discussed several topics today, however, two of the most powerful were transparency and shared decision making. After reviewing the story of Michael Skolnik, my heart ached for families that have suffered similar loss. For the Skolnik family, the loss was intensified by the lack of transparency and shared decision making. As an advanced practice nursing student, I witnessed a situation in which transparency and shared decision making was present in an otherwise unfortunate event. A patient arrived to the hospital in the midst of his second heart attack. After stabilization, options were presented with one being coronary artery bypass surgery. The patient chose bypass surgery, however, his surgery was on hold for coagulation issues. When it was time for the patient to have surgery, an emergent patient arrived necessitating a potential delay in the first patient’s bypass. Transparent communication occurred between the patient and provider detailing the situation and… Continue reading

Communication and the Optimism Bias

Communication, teamwork, team-coordination – all buzzwords of patient safety and improved healthcare system performance. But does everyone truly know the meaning of these terms? We were presented a case study today in which an experienced and revered surgeon encouraged his surgical team to break protocol by closing a patient when the sponge count was off by one sponge. The surgeon cited, with amiability, the length of time under anesthesia as the urgency for ending the procedure before the missing sponge was accounted for – and rightly so, as longer times under anesthesia are associated with decreased patient outcomes.  However, so are surgical materials left in patients. The concerned team deferred to the surgeon’s congenial and persistent request for the sutures to close the patient.

At first glance, this team could be considered to have some of the above qualities: they communicated about the missing sponge, they coordinated a course… Continue reading

“No decision about me without me.”

Day #2 of the Telluride Summer Camp was even more invigorating and inspiring than day #1. Between John Nance’s talk and the film about the Skolnick family, I feel that my fellow students and I have been given a call to action. The resonating statement that summarizes our new mission was said, of course, by Dr. Donald Berwick himself: “No decision about me without me.”

The principles of shared decision-making, transparency, and patient-centered care all revolve around the concept that the patient is the subject of our care, not the object (as so eloquently put by John Nance). If we consider the patient as a living, breathing individual, then we would certainly reconsider some of the daily decisions we make in healthcare that we consider mundane. One can argue back and forth to what level the patient should be involved in their own care (i.e. should we obtain permission for… Continue reading

Day 2 Reflections

Shared Decision Making – perhaps better known as Informed Decision Making
— It would be interesting to have stock videos to educate patients about procedures, but this has to be used in conjunction with explained. (apparently this occurs with a single company out there)
— It would be cool to have specific consent forms for specific conditions that look like this (see attached pic):
— We have to be careful with numbers (risk) and make sure it’s meaningful and the data is being applied correctly and that the numbers cited are actually applicable to the case at hand.
— We can’t rely overly on numbers as there are certain things we can’t really quantify: for example, I can tell you that the rate of infection for LP is 5%, but I can’t quantify the risk of not doing the procedure – it’s hard for me to say you have… Continue reading

#TPSER9 – Telluride Student Summer Camp Reflections on USA Today Article and more

By Aaron Cantor, BS, ENS, MC, USNR, MSII Pennsylvania State College of Medicine

On my way back home from Telluride, I happened to pick up a copy of USA Today from 20 June.  I was pleasantly surprised to see that the front page featured a special report, “When Health Care Makes You Sick: Under the knife for nothing.”

Although the article highlights medical errors, interviews Lucian Leape and Rosemary Gibson, and even mentions the story of Michael Skolnik, its tone perpetuates acceptance of medical errors and withholding of valuable information:  there is a way to know the total number of cases in which people got surgery that wasn’t needed if honest disclosure is practiced; hospitals are required to report infection and surgical errors to a governing body, but reporting to the patient and family (those who are most affected) may not be required.  The article… Continue reading

Infection Rates: It’s not just transparency, it’s informed consent

One of the highlights of the Telluride Patient Safety Summer Camp was the in-depth discussion of the meaning of informed consent. It is not as straightforward as “here, sign this”. In fact the paper consent itself is in a sense the last and least component of informed consent. I was a bit surprised and secretly glad to hear some places have rid themselves of the informed consent form, which reinforces the notion that informed consent is some kind of administrative scut to be dished out to residents. Informed consent isn’t extra, it isn’t something for special procedures, it really should be an integrated part of every doctor-patient relationship. The heart of it is shared decision making and coming to the best course of action based on the patient’s preferences, values, needs, and goals. (“Preferences, values, needs, and goals” was in fact one of my takeaways – a mental checklist… Continue reading

AELPS 2022 Dates

- CMF Scholars (Week 1)*: 6/5/22 - 6/9/22
*Session exclusive to COPIC Medical Foundation Residents.
- Sorrel McElroy Scholars (Week 2): 6/12/22 - 6/16/22
- Bennathan Scholars (Week 3): 7/19/22 - 7/23/22
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