Addressing Patient Preferences Appropriately

"Diagnosing" a patient's preference requires communication skills

During a recent meeting of the Patient Safety Committee, Chair David Ring, MD, PhD, facilitated a discussion focused on identifying and responding to patient preferences in treatment. Participating committee members Dwight Burney, MD; Michael Pinzur, MD; Alan Reznik, MD; Andrew Grose, MD; Chris Gaunder, MD; Ramon Jimenez, MD; and Michael R. Marks, MD, MBA, shared strategies.

Dr. Ring: The concept of shared decision making has had some impact, but there is still room for improvement. Variations in the rates and types of treatment can be found among surgeons. It seems intuitive that we, as orthopaedic surgeons, might judge the effectiveness of the shared decision-making process in terms of decreasing surgeon-to-surgeon variation. If we are accurately identifying our patients' preferences and merging them with best practices, the variation should be from patient-to-patient rather than surgeon-to-surgeon.

It might be beneficial to reframe the issue in terms of quality and safety. For instance, we might want to talk about misdiagnosis. We are at risk of an error in diagnosing a patient's preferences. It may be more compelling to focus our efforts on avoiding a misdiagnosis of the patient's preferences.

Sometimes initial preferences are based on misconceptions—either the surgeon's or the patient's. Other times, the patient may not be aware of his or her own values.

As surgeons, we need to encourage patients to reflect and to get to the heart of what they value. We might ask a patient: Do you hope to avoid surgery? Are you confident you can draw on your resiliency if it will help you avoid surgery? What investments of hope, time, discomfort, and resources are you willing to make? What would you want in return?

Once patients are aware of their values, do they really see all the options? Do they understand, for instance, that nonsurgical treatment is an option?

Open communication between surgeon and patient can lead to accurate identification of a patient's treatment preferences.
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Consider a clavicle or humerus fracture. A person with deformity, pain, bruising, crepitation, and a radiograph showing the bone clearly out of place may not be confident that his or her body can heal on its own or that he or she could adapt to residual deformity. Patients who have thumb arthritis and feel that something needs to be done may not understand that adaptation and resiliency are good options—ones that many, if not most, people use effectively.

How do we, as surgeons, make sure patients understand and are aware of their values? How do we ensure that they see all the options so they can make a choice they will not regret? Decision aids with easy-to-read, balanced, and dispassionate information that can be reviewed with family and friends may help.

What else can we do to lessen the chance that we misdiagnose our patient's preferences?

Dr. Grose: Most patients have a clear preference, particularly when the choice is between surgical or nonsurgical treatment. But for those who don't have a clear preference, I spend some time with them explaining the options.

Dr. Ring: Remember, evidence suggests that conveying empathy is more effective than spending time. In other words, it's the quality—not the quantity—of the communication.

In particular, we must be aware of when it feels like we are trying to convince the patient of something, or when some type of debate is ongoing. That's unlikely to be a productive discussion or time well invested.

Consider a 70-year-old woman who lives independently, but is low demand, who breaks her distal radius. After you establish a relationship and get to know her, you can start to convey your expertise, perhaps by saying "This is going to heal" and then pausing. This will put her at ease while you wait for her to nod or ask a question.

Next, you might say, "It could heal with a little bit of a bend." Many patients will interject at this point and say, "I don't mind how it looks." Then you might say, "You might have a little trouble bending the wrist down, and maybe a little trouble turning it." With this step-by-step approach, within a minute or two, you have given the patient a sense of how nonsurgical treatment will result.

Then you can introduce the option of surgery, by explaining that it is the only way to get the wrist to heal in a better position. At this point, you need to be silent and let the patient respond. Some people might say, "I'd like to avoid surgery if possible." Others will say, "I'm interested in surgery to get my wrist aligned as well as possible."

People don't need a lot of information on anatomy or evidence to identify their preferences and understand their situations. Saying "Does that fit what you were thinking?" or "Tell me what questions come to mind" will elicit questions better than "Do you have any questions?" which tends to close off the conversation. It's important to make sure we, as surgeons, are doing as much or more listening than speaking.

Dr. Pinzur: As a foot and ankle specialist, I see many patients who are seeking limb salvage. They may have long-standing diabetes with deformity and infection, and they look to me as their great savior. I sit down with them and say, "Let's talk about the spectrum of options." I start with amputation and I work toward accommodative bracing. I say, "We have to figure out where you fit in this spectrum and what's right for you."

Dr. Ring: One useful approach may be to start with the option the patient has pinned his or her hopes on. It validates the patient's way of thinking. It's important to establish that relationship and to convey empathy. It can help to give the patient three options, with the option you want to receive more consideration in the middle.

Dr. Marks: That makes sense. If you don't address the patient's ideas first, you may be perceived as dismissive.

Another technique is to ask patients what they already know about the problem: "Tell me your understanding of what is going on." If you're not on the same page, you can at least say, "I can understand why you're talking about that," which validates their thought process.

Dr. Ring: That fits the adage that patients don't care what you know until they know that you care.

Dr. Grose: I spend a lot of time with the subset of patients who have trouble deciding.

Dr. Ring: To establish empathy, you can say, "You know what? This is a hard decision." Then maybe you can introduce a decision aid and ask, "Would you be willing to try this?"

These are difficult discussions and it's important to be aware that orthopaedic surgeons have some of the lowest ratings nationally on empathy and effective communication. I don't think we'll be able to train every orthopaedic surgeon to be an excellent communicator. Evidence suggests that what makes us good at the technical aspects of our work—characteristics such as stress immunity—are at odds with the nontechnical aspects of our work, such as empathy.

We should take advantage of opportunities to practice communication skills. We might also take advantage of decision aids or navigators—people whose job is to help a person identify his or her preferences. We can advise people by steering them to websites that will take them through the options and help them understand what they want.

Over the years, I have found that spending more time with a patient doesn't always help. At the end, the patient often felt that we were arguing or that I was trying to convince him or her of something. The decision aid might help depersonalize these discussions.

Dr. Jimenez: I like to get the conversation to "What is your goal?" and "How can I help get you to that goal sooner?" Even people dreading amputation might then realize that amputation may be the quickest way to achieve their goal. For patients with difficult limb salvage issues, typical goals are to be active, to play with the grandkids. Spending 2 years trying to save the leg with multiple surgeries might not be the best approach.

Dr. Ring: That's a nice technique for avoiding misdiagnosis of patient preferences. It's sometimes referred to as motivational interviewing. If patients think that they have to keep a leg to be the kind of person they want to be, motivational interviewing might help them realize that other options are available. The discussion becomes something like: "This path gets you to your goal 50 percent of the time, while this other path gets you there closer to 100 percent of the time." This may increase their openness to options that they were not considering.

Editor's Note: This is the first of a two-part roundtable among members of the AAOS Patient Safety Committee on identifying and addressing patient preferences.