Sunday night’s (09/18/11) HCSM Tweet Chat discussed if physicians should point patients to social media, do physicians know if patients are using social media, do they care, and does it matter?
Data has shown that the majority of patients want to be active in their health. Shared Decision Making (SDM) is a proven tool to engage a broad cross section of patients to actively participating in their health care. An added benefit of SDM is that it can engage people with low health literacy and disadvantaged groups. These groups defer to the physician and have poorer outcomes. Physicians engaging in SDM (shared learning) motivate underserved patient populations to become active in their health care. SDM improves outcomes for all patients who are active in their health care.
Shared decision making (SDM) is when patients and physicians work together to select tests, treatment, disease management, and support all based on evidence and the patient’s informed preferences. Shared decision making embraces the patient’s right to make decisions about their care. Both parties commit to sharing information and decision-making responsibilities. It sounds surprisingly like the ePatients, SM, and the Twitter #hcsm chat on Sunday night. Informed patients who are part of the health care process with their physician have better outcomes.
The physician directing the patient to social media is giving tacit approval for the patient to be actively engaged in their health care. Patient and physician are partners in learning. Social media is one tactic in the uptake of knowledge and resides on a larger continuum of learning. Both SDM and SM are part of a learning strategy that have a great deal in common.
When the SM discussion takes place, the physician and patient are engaging in knowledge and learning to improve outcomes. We can assume the patient is either familiar with social media or not. If patients are familiar with SM, we can assume they are active in managing and learning about their health care beyond social media. If they are not familiar with or participate in social media, they may or may not be active in learning about their health. For purposes of this essay, I will assume they are not. This as a binary model looks like the following:
Physician: 0: Wants a patient knowledge partner
1: Wants a less active patient knowledge partner
Patient: 0: Is a knowledge seeker
1: Is not a knowledge seeker wants to be lead
The 0 physician and the 0 patient are a great match because they work together in managing health care. The 1 physician and the 1 patient are also a good match, because they reside in the same space: physician leads, patient follows. Can the 0 physician motivate the 1 patient to become a 0 patient. Will the 1 physician demotivate the 0 patient?
SDM has been well studied and is primarily used in chronic and terminal illnesses or making choices between surgical or medical treatment. The UK is currently examining mandating SDM within the NHS. A study titled “Making Shared Decision-Making a Reality” ‘No decision about me without me’ by Angela Coulter and Alf Collins examines SDM in great detail. http://tiny.cc/0x59e
From that study, Table 1 presents what I see as the bridge between SDM and the ePatients, SM, physician, etc.
A key principle in adult learning is sharing of experiences (expertise) between adults, which create reflection that may become action (change in behavior, new knowledge, etc.). Physicians as noted above have extensive experience/expertise, which they apply to patient management. When patients’ own expertise/experiences are added to the physician’s, new knowledge is created which changes patient management and improves care and treatment.
SDM is a well structured and managed process relying on patient decision aids and tools to help patients understand and participate. Knowledge and information used by the patient to make decisions is provided by the HCP. It is part of the SDM contract. In SM the patient is a self-learner. They seek knowledge from others and other sources. The physician approving or pointing the patient toward SM and learning is performing a less structured more open ended SDM. The question now becomes, if SDM works and improves outcomes and benefits patients, how can we apply and frame those SDM principles along with adult learning to the SM discussion? Can we improve the health care relationship between physician 0 and patient 0? How can physician 0 motivate patient 1 to become an active participant in their health care?
There are some simple steps the physician can do prior to pointing patients to social media:
• Have the patient fill out a short form asking about their knowledge of their disease, confidence in that knowledge, what is their primary source of information, etc.
• What problems specific to their disease/visit do they want to solve?
• If they have done research or participated in social media what did they learn that changed their opinion about their disease?
This short simple exercise prior to the exam yields a great deal of information that incorporates the patient’s experiences/expertise with the physicians’ own perspective to create a new set of knowledge. With this understanding the physician can proceed with the examination and begin to help patients better articulate their problems/needs. In addition, the physician can better guide the patient in their learning moving clinical management closer to the evidence because they are both basing care on shared knowledge and trust. In the end, determining what the patient knows, what are their experiences, and how have they incorporated that knowledge will improve management and outcomes. This information is as critical as the physical exam. It should be part of the patient chart and updated at each visit. Besides tracking physical progress, the physician can track knowledge progress and compare the two.
Pointing patients to social media in and of itself is not a stand-alone activity that yields the greatest benefit. Framing the discussion of SM with an understanding of the patients’ current knowledge base and problems they are seeking solutions for will go a long way to improve outcomes and care. SDM is proven model that can be applied as stand-alone or its principles adapted to physician patient learning. In either case SM alone is only part of the solution to improving health care and outcomes.
This process may take more time upfront but, data demonstrates it yields better outcomes and in the long term saves time and cost. Framing social media recommendations within the larger context of a patient needs assessment is a better model.