Learning Objectives:After participating in this continuing education activity, the provider should be better able to:
1. Describe the shared decision-making process.
2. Explain the role of shared decision-making in obstetrics and gynecology.
3. Select decision aids and evidence-based medicine in the shared decision-making process.
In recent years, there has been a consistent trend to steer away from the paternalistic model of decision-making in health care. The practice of patient-centered medicine and shared decision-making (SDM) has been strongly encouraged. The Institute of Medicine defines patient-centered medicine as "providing care that is respectful of and responsive to individual patient preferences, needs and values."1 Within the delivery of patient-centered care, SDM seeks to combine current evidence-based practice with patient values to involve patients in their own plan of care.2 SDM is defined as an approach where clinicians and patients discuss the best available evidence and work together to reach decisions that balance risk and patient preferences. It is currently the ideal structure for patients and health care providers to engage in clinical care.3
SDM respects both the expertise of doctors and right of patients to informed consent because the approach provides patients with the knowledge they require to make customized health care decisions.4 The SDM model encourages patients to become advocates for their health and to consider the benefits and harms of all available screening, treatment, and management options. In SDM, the responsibility of the health care provider is to empower patients to choose interventions that match their needs and lifestyle by ensuring that each patient is well informed.5 SDM is beneficial in regard to patient satisfaction and compliance, clinical outcomes, and overall quality of life.
The notion of creating a "shared decision-making model" to involve patients in their own care has been emphasized at a national level.6 However, the SDM model has not been well-studied or well-used within the field of obstetrics and gynecology. SDM can be used in both surgical and primary care to help patients navigate preference-sensitive reproductive health decisions. It is crucial that physicians emphasize patient morals, experiences, and cultural backgrounds when discussing women's health. In this article, we discuss SDM as it applies to the field of obstetrical and gynecological health.
Evolution of Shared Decision-making
Shared decision-making was first mentioned as the "appropriate ideal for patient-professional relationships" in the 1982 President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavior Research. The Commission's survey explained that 56% of physicians and 64% of the public felt that increasing patient involvement in the decision-making process would improve the quality of care that patients received.7 However, it was revealed that respondents were often referring to the use of educational pamphlets or instructions that did not qualify as tools used for SDM.8 Thus, the principles of SDM were well-received but were not appropriately implemented into routine clinical practice.
In 2007, legislation was passed in Washington State incentivizing SDM as an alternative to traditional informed consent for elective procedures. The decision was made based on data that showed the use of high-quality decision aids improved doctor-patient communication and ultimately led to better-informed patient decisions.9 In order for SDM to supersede the practice of informed consent, physicians were required to use certified decision aids to discuss the various treatment options for an elective procedure. At the same time, patients needed to confirm that they reviewed the decision aid and participated in discussion about the alternatives, risks, and benefits.8
A 2014 Cochrane review of decision aids analyzed 31 studies that focused on reproductive health decisions. Although a majority of the studies showed no evidence of an effect on treatment choice, they proved to have a positive effect on patient-centered outcomes of care, medication adherence, patient anxiety scores, and quality-of-life measures.3 It was not until 2016 that Washington State certified the first decision aids in maternal-fetal care, using decision aids to discuss birth options after cesarean delivery, amniocentesis, and genetic screening.8 Since then, little has been done to more clearly determine the role of SDM on important aspects of patient-centered care, especially within the field of obstetrics and gynecology.
Shared Decision Making in Obstetrics and Gynecology
During obstetrical and gynecological visits, physicians and patients regularly discuss a range of sensitive topics including but not limited to obstetrical decisions, screening options, abortion care, contraception options, fertility awareness, and management of malignancy. Although patient values and needs should be at the forefront of these discussions, there has been limited research on the crucial role of SDM within the field. That said, we discuss examples of how SDM is being incorporated in select obstetrical and gynecological situations.
Family Planning
SDM in obstetrics and gynecology has most commonly been used in discussion of family planning, specifically contraception and abortion practices. Roughly 45% to 50% of pregnancies in the United States are unintended, and the rate of unintended pregnancies is even higher in women of color and low socioeconomic status.10 A major contributing factor of unintended pregnancies is the incorrect use or nonuse of contraception. When choosing a contraception method, 50% of women feel pressured by their provider, and many feel that their concerns about side effects are not properly addressed during the contraception counseling.10
In response to these reports, an interactive electronic patient-centered contraception decision aid was developed in 2016 at the University of California to be used before physician counseling. It was systematically developed to prioritize women's preferences by including an educational session, clarification of patient's preferences, health history, frequently asked questions, and contraception profiles. Approximately 96% of patients reported satisfaction with the information provided and claimed that the decision aid was beneficial in the decision-making process.10
The quality of patient-provider communication has also been shown to be an important component of health care quality for contraception counseling. A prospective cohort of 348 women reported that with high interpersonal quality counseling patients were more likely to maintain use of their chosen contraception method and to be using intrauterine devices or implants at 6 months.11
SDM is used when physicians counsel women on abortion-related services. A qualitative exploration of abortion preferences concluded that women value having the option of abortion and having access to their preferred mode of abortion. Additionally, Altshuler et al12 emphasized the importance of providing sufficient information before abortion procedures in order for patients to properly prepare.
Just as SDM is critical when discussing abortion, it is just as beneficial upstream when discussing preconception questions and planning. In 2018, a randomized control trial evaluated the effectiveness of a "pregnancy intention" screening tool to assess physician-patient communication about reproductive plans. Patients reported that the screening tools helped facilitate conversation with their providers and improved awareness about their options.13 These screening tools benefited direct physician-patient counseling within obstetrics and gynecology.13
Obstetrics
In obstetrics, SDM can be implemented in various areas. For example, the American College of Obstetricians and Gynecologists has endorsed the use of SDM in prenatal screening and diagnostic testing. Currently, there exists a wide variety of prenatal screening tests, each offering multiple levels of information and accuracy. The panoply of testing options reinforces the importance of proper counseling. Screening for aneuploidy should be an informed decision made by patients taking into account their personal situations, values, interests, and goals.14 When parents are faced with making critical decisions for ill infants whose outcomes are unpredictable, SDM has been incorporated during antenatal consultation. This model is used to provide resources and empower parents to make personalized decisions, idealized to their values and goals, during the antepartum period and after birth.15
SDM can also be used intrapartum to guide patient decisions during labor. Goldberg et al16 found that the degree to which patients experience informed decision-making when using epidurals during labor differed from provider perception. Providers were more likely to recall using the proper SDM model, whereas the patients were less likely to believe that their rights to make informed decisions were supported when decision aids were used.
Discussing mode of delivery after cesarean delivery in a previous pregnancy represents another common and useful example of using SDM in obstetrics. Women who are candidates for a trial of labor should be adequately counseled on the risks and benefits of a vaginal delivery after a cesarean delivery. An SDM model uses provider knowledge, comfort, and experience to counsel women on the proper mode of delivery based on a woman's values and goals. Emmett et al17 explain the use of decision aids and numerical values to provide proper counseling and maximize the patient's ability to understand the risks and complications of both vaginal birth after cesarean delivery and an elective repeat cesarean delivery.
Infertility
The treatment options for infertility are dependent on the causes of infertility and patient goals. Once patient goals are established, providers can follow decision points that prompt the proper pretreatment, treatment, and posttreatment questions.18 Decision points are another tool within the SDM model that help physicians guide patients through a challenging decision-making process. An additional set of decision points are available to help link the many causes of infertility and associated treatments, as these are often confusing to understand and explain.18
Research discussing SDM and infertility focuses on young patients with cancer who must decide whether to opt for fertility preservation before cancer treatment. Patients often find the numerous treatment options overwhelming, especially when their decisions are so clearly time-sensitive. Decision aids offer additional support, helping patients to make these urgent decisions in the best way they can with the hope that they will minimize the likelihood of later regret.19 They were used to determine the effectiveness of additional support for women discussing fertility preservation with their physicians. In a randomized control trial, 27 women received fertility preservation counseling and 24 women used an online decision aid in addition to traditional counseling.20 The women who used the online decision aid immediately after counseling had significantly reduced short-term decisional conflict.20 The effectiveness of the decision aids and decision points indicates that SDM is beneficial for patients when addressing infertility with their physician.
Cancer Management
Since 2001, SDM has been integrated into physician-patient discussion of breast cancer treatment options. An "Interactive Breast Cancer CD-ROM" was developed as a decision aid for patients with stage I or II breast cancer to improve decision-making between breast conservation therapy and mastectomy. Although the CD-ROM did not influence the choice itself, it had a significant positive effect on patient satisfaction and quality of life. According to Molenaar et al,21 quality of life was measured by general health, physical functioning, and pain, and patient satisfaction referred to the information on the CD-ROM. Other studies on SDM in the surgical treatment of breast cancer have confirmed that decision aids guide both providers and patients to make informed decisions, increase patient knowledge, and decrease decisional conflict.22
Components of Shared Decision-making
The goal of SDM is to improve quality of care, but it is heavily dependent on patient involvement. When practiced successfully, SDM has been shown to strengthen patient involvement, satisfaction, and knowledge; yet there is a lack of guidance on how to incorporate SDM in the clinical setting. Beers et al5 outline 4 important steps that must be implemented in order for patients to benefit from SDM models and decision aids. First, the patient must be informed that there is a decision that needs to be made. Second, treatments options need to be comprehensively explained. Third, providers must identify the patient's values and goals. At this point, the physician has suggested appropriate, applicable options, and the patient should feel confident about making a decision. The options offered should be tailored to the patient's preference. Finally, follow-up is arranged. Patients should be given the opportunity to evaluate all options and review decision aids. Sometimes this involves making decisions at future visits or following up with the patient and/or trusted loved ones to ensure the decision made remains appropriate.5
To demonstrate these steps, we present an example of SDM implemented into a typical physician-patient discussion within obstetrics and gynecology (see sidebar).
In this case, the patient is informed of her diagnosis and that a decision regarding her care must be made. She is presented with treatment options as stated by the appropriate evidence-based guidelines. Her values and difficulties are identified and discussed, as she acknowledges her stressors and the advantages and disadvantages of each treatment option. Finally, a decision is made that both the provider and the patient deem safe and proper, and the patient receives follow-up instructions.
The Informed Medical Decisions Medical Foundations model outlines a framework to assist providers in incorporating SDM. As a first step, this model stresses the importance of the physician inviting patients to participate in the decision by sharing the fact that more than a single first-line treatment may be available. This step allows patients to understand that their goals and values are important in the decision-making process. Second, the provider should present all available options. Third, the doctor should provide balanced information on the risks and benefits of the available treatments, and should present statistics and numbers in the place of words to avoid overestimation of the benefits and underestimation of the risks. Fourth, the provider should afford the necessary time and space for patients to raise their treatment concerns to assist them in fully understanding their options. Providers should actively encourage patients to express their preferences. Fifth, the provider should facilitate deliberation and decision-making with the patient. Many times patients are not ready to make decisions immediately and providers should explore what other information they might need. Finally, the provider should assist with implementation. At this point a decision has been made and information on the next steps is laid out for the patient.23 A sample of the steps and example phrases using this model is shown in Figure 1.
Case
The patient is a 27-year-old G2P1001 woman with a history of uncomplicated full-term vaginal delivery 3 years ago. She presents to the emergency department with vaginal bleeding. Her vitals are all within normal limits, physical examination is unremarkable, and she is hemodynamically stable. She has regular 28-day cycles and reports a last menstrual period 7 weeks 5 days previously. She has not been using contraception. Serum [beta]-human chorionic gonadotropin ([beta]-HCG) is 400 and transvaginal ultrasound is significant for a 3-cm left adnexal nonovarian structure, no intrauterine pregnancy, and no free fluid. After the proper evaluation, follow up is performed 48 hours later. Her serum [beta]-HCG is 420 and she is diagnosed with a nonruptured ectopic pregnancy.
The patient is provided with treatment options of medical versus surgical management. The risks, benefits, and subsequent follow-up of each option are thoroughly explained. When asked about her thoughts on the treatment options, the patient reports that she is worried about surgery and recovery, as she is a single mother with a toddler and a full-time job. She states she would like to avoid a surgical procedure if possible. The patient is once again counseled that she may still need surgery if medical management fails. Ultimately, she decides on medical management. She is then thoroughly counseled and provided with proper follow-up instructions.
Decision Aids
The physician-patient relationship is crucial in both SDM and informed consent. Although both are focused on value-based care, SDM incorporates decision aids to facilitate discussion about treatment options.8 When facing several treatment or screening options, decision aids support patients by describing treatment options and outcomes based on a careful review of the evidence available. Examples of decision aids include "option grids" that present every option together and "Cates plots" that use visual aids such as "smiley faces" to present treatments clearly and without bias.18 Patients are typically advised to work through the decision aids on their own time. They are encouraged to weigh the importance they place on potential outcomes and then discuss their findings with their physician before making a final decision.24 In a 2017 Cochrane review of 105 randomized control trials, the use of decision aids was compared with usual care or alternative innervations. The review concluded that patients exposed to decision aids felt more knowledgeable, better informed, and were more satisfied with their decision compared with those given typical care.24 A meta-analysis of breast cancer treatment options confirmed that patient knowledge increased by 24% when physicians implemented decision aids into discussions. These patients also reported more involvement and less anxiety in their health care decisions.22
Overall, decision aids improve patient confidence and play a pivotal role in decision-making. They are designed to support SDM by providing easy-to-understand evidence-based information about the benefits and risks of different treatment options. It is imperative that each decision aid undergo a certification process before its introduction to the public. The National Quality Forum has spearheaded this process by issuing criteria for decision aid certification. The decision aid criteria ensure that high-quality, evidence-based information is offered to patients with the goal of improving patient-clinician communication and patient satisfaction.
How to Incorporate Shared Decision Making
Studies on SDM have been focused primarily on situations in which patients make one-time decisions, such as surgery. In fact, an SDM strategy should be used in most health-related decisions. Recently, health providers have been integrating SDM models into physician-patient discussions about ongoing lifestyle changes and management of chronic comorbid conditions.25 Wexler described 3 clinical scenarios in which SDM can be used.23 First, if more than one option exists in which the expected outcomes provide equal benefit, then the patient's preference should be given priority. The second scenario involves evidence-based interventions, in which the outcome of a given treatment has proved superior to alternative treatments or declining treatment. The third scenario includes interventions for which there is uncertainty about the benefits and harms associated with treatment or no treatment.26
Previous studies have shown that provider support is the most important factor in patient decision-making.27 Integrating the SDM model into physician practice strengthens the physician-patient relationship and encourages patient participation. Nevertheless, many physicians seem to struggle in making this transition. Consequently, in some of these interactions, patients are dissatisfied with the level of participation they perceive to have in making choices about their health.27 Providers are encouraged to reflect on their approach toward counseling patients to ensure they understand the benefits, risks, and alternatives. Providers should also be mindful of their influence in the decision-making process and ensure that choices are consistent with patient preferences and free of coercion. During counseling sessions, a patient's knowledge and understanding of the information provided should be evaluated. Patients need to be encouraged to take responsibility for their knowledge during the decision-making process. Emphasis should be placed on their knowledge and understanding of the risks and benefits to their decisions.
It is imperative to acknowledge the importance of proper communication when implementing the SDM model. Patients are encouraged to communicate their preferences and physicians must understand these values and goals to establish rapport and build trust. By starting a conversation and respectfully responding to patient concerns, physicians begin to build the foundation of SDM. Throughout the counseling process only patients' preferences should be considered, and providers must remain an unbiased source of clinical information to guide and empower patient decisions.28
When first interviewing patients, physicians may ask open-ended questions and allow patients to speak for 20 to 30 seconds before implementing the SDM model.26 Using the 4 components or the 6 steps of SDM as a guide, health care providers can further incorporate relevant decision aids and evidence-based guidelines when counseling patients. Health care providers must be knowledgeable about the most current evidence, and they should present the information in a manner to ensure patient understanding. Finally, proper language should be used during counseling. For example, using whole numbers instead of percentages or probabilities has been shown to improve patient comprehension. Words such as "rare" and "unlikely" should be avoided.29
Conclusion
Providers of obstetric and gynecologic services face a unique set of obstacles centered around the cultural, physical, social, and emotional aspects of patient care. The recent advancement of SDM has greatly impacted the quality of care provided to patients. The SDM model is an effective approach for providers to use when guiding patients through difficult decisions in both the primary care and surgical components of our field. The evolution of decision aids and evidence-based guidelines has aided in the implementation of SDM in clinical practice. That said, further research, in all areas of obstetrics and gynecology, is needed to determine how to best integrate SDM into the specialty.
REFERENCES