As we continue to focus on shared decision making within the context of value-based care, one of the primary goals is the prevention of over treatment through better communication. To improve our conversations, we must first unearth any underlying components that impact both the patient and the provider.
Disease uncertainty and management choices can evoke strong psychological reactions that can result in the patient’s desire for more extensive treatment. Anticipated regret or the “what if” scenario occurs when the fear of not undergoing therapy, even if the chances of improvement are slim or the side effects are significant, will result in a reoccurrence. For those same reasons that lead one to purchase a lottery ticket, our human nature allows us to imagine a possibility effect – a situation when the stakes appear to be so high that we choose a course of action with an insignificant potential gain that barely deviates from futility. Furthermore, we all have existing beliefs and biases that are formational to our thinking and decision making. This confirmation bias is our tendency to discount useful information that conflicts with our current ideals. This constraint is compounded when we are emotional, as logical thinking becomes difficult.
Just as the patient enters into a discussion with a bias, physicians’ emotional state and experiences also shape conversations. Handling difficult exchanges are further complicated by our prejudices. As we physicians are hopeful by nature and are driven to diagnose and treat, we risk allowing ourselves to fall into similar biases and effects, such as the scenarios described above. Both positive and negative experiences further impact our recommendations or even frame references while partaking in discussions. The hardest question to answer is, “doc, what would you do?”
How do we overcome these problems? Recognizing the psychological dynamics is the first step. Merely understanding their existence and stating that they are real will mitigate their power. Creating space and time for these difficult conversations to occur is also paramount. Remembering that our brain needs to time to process complicated information is essential. Providers need to understand and comprehend their own biases and have tools to remind themselves when and how they are triggered. Learning as much about ourselves and who we serve is vital within both the physiologic and psychologic spheres. Advances in precision medicine will also help alleviate many situations by removing options that are proven to have no value.
Communication and shared decision making are subjects that have more significant complexity than just understanding their importance and being more cognizant. Just as we are trained to be excellent diagnosticians and to continually challenge ourselves to follow all new evidence and treatment modalities that are changing with greater frequency, we must also focus on learning the nuances of communication skills and their advances. Though this challenge might seem overwhelming, the results will only enhance the value received by those we serve and elevate the joys of our vocation.