View from the ground, by Dr Sally Lewis

The other day I was in conversation with a group of ophthalmologists who were analysing their outcome data from cataract surgery. The discussion centred around a small but significant group of patients who reported no benefit from surgery in terms of their visual functioning, measured by a validated patient-reported outcome measures (PROM) tool, the Catquest-9.

For a procedure like cataract surgery this seemed surprising to me, particularly as the poor reported outcomes were not necessarily related to complications or post-surgery visual acuity.

Visual functioning, I learned, was about more than visual acuity and there are definite trade-offs between early and later intervention. We see this with many preference-sensitive scenarios in medicine. Another example would be knee replacement surgery, where a similarly small but significant proportion of patients are also less than satisfied after surgery. It seems likely that these situations arise at least in part from a mismatch of expectations between clinician and patient. It made me reflect on the shared decision making process again and wonder, how good am I?

Meaningful shared decision making is not the fluffy preserve of touchy-feely general practice. It is an essential part of excellent medical care. It relies on a number of factors. Firstly, a common understanding of the problem and an exploration of the priorities and goals of the person we are caring for is an essential foundation to the conversation. Then we need to figure out together how we are going to meet those goals, navigating through evidence-based guidelines. How often have I made assumptions about what matters to my patient and defaulted to action too quickly, generating either a referral or a prescription?

Secondly, a detailed knowledge and appreciation of the pros and cons of all treatment options available is needed along with any supporting tools to help select options. Some people find decision grids helpful here, some don’t. Having the right information, presented in the right way, for every single clinical scenario during a surgery is a challenge.

Thirdly, having the confidence to present ‘doing nothing’ as an option.

Finally, and arguably the most important factor whether we are discussing new medications, a referral, or advance care planning, is time. Time to listen. There is no way I can do this well in a 10-minute consultation.

If we are to support patients in the way we would like to, I suggest we must think creatively about how we can do this well. Longer consulting times may be a pipe dream, at least in the short term. Can we deploy other resources to support this important process over time, perhaps through the involvement of other healthcare professionals? Can we find new ways for people to access the necessary information so that they can weigh up their options more autonomously?

So am I any good at shared decision making? Ask my patients. The proof of the pudding is in the outcomes that matter to them, and nothing else.