Editor’s note: This is part one of a two-part series on shared decision making. Part two, which will appear in the November issue of AAOS Now, will present an illustrative case where missing the basic tenets of shared decision making led to an unsatisfactory patient experience.

Physicians cannot ignore the nontechnical, soft skills and still be successful

In 1998, AAOS conducted an image perception survey, the results of which revealed that the public viewed orthopaedic surgeons as “high-tech and low-touch.” Since then, AAOS has been dedicated to improving communication between its members and their patients. In 2001, it teamed up with the Institute for Healthcare Communication, a nonprofit organization, to launch the AAOS Communication Skills Mentoring Program. To date, more than 8,000 physicians have attended approximately 400 practical communication skills workshops.

Communication skills are one of the six core competencies that residents are expected to acquire during training, and many program directors see the Communication Skills Mentoring Program as a way to check this box. As it turns out, this nontechnical skill is like many other skills we as physicians must master: If we don’t practice it, we won’t become proficient. Additionally, it is well documented that residents model behavior after their mentors. Thus, it is important for faculty mentors to be equally adept in such nontechnical skills.

The workshops introduce the premise and skills necessary to improve communication. The first thing attendees do is compile a list of the various frustrations they encounter when dealing with patients, of which there are many. The complaint most consistently noted is dealing with noncompliant patients. It is easy to fully understand this frustration. When we tell a patient to do something, and they don’t follow our instructions, we feel frustrated.

But are patients really being noncompliant? Compliance is a legal term that applies to outside rules and regulations that govern behavior. For example, not obtaining mandatory continuing medical education credits to maintain a medical license is a compliance issue. When patients don’t follow our instructions, they are actually being nonadherent—in other words, they aren’t sticking to the plan we have laid out. According to multiple studies, reasons patients don’t adhere to our plans for them include the following:

• They did not understand our instructions (7 percent).
• The instructions are against their personal beliefs (20 percent).
• The instructions were too difficult (25 percent).
• They have cost concerns (27 percent).
• They disagreed (39 percent).

All these reasons underscore the importance of communicating with patients. If we don’t gauge our patients’ understanding of and opinions about our instructions, how do we know they will adhere to them?

Consider the following true scenario:

A 45-year-old male was brought to the emergency department (ED) at 2 a.m. after sustaining an injury on the job. The ED physician examined him and diagnosed an acute lumbar sprain. The physician gave the patient three prescriptions and told him to follow up with me in 10 days.

During the initial follow-up visit, I inquired how he was feeling. He stated he was still having pain, and I asked about his prescriptions. The first was for physical therapy (PT). He said he didn’t go! I thought, “No wonder he isn’t better.” However, when I asked him why not, he told me he was a single dad who worked nights. He gets home from work at 7 a.m., wakes his two children, feeds them breakfast, and puts them on the school bus. He then goes to bed and sleeps until it’s time to get his children off the school bus, help them with their homework, and feed them dinner. He then leaves for work. With his schedule, he has no time for PT. He stated that he tried to go on the weekend; however, no facility would see a new patient on the weekend for a first visit. His explanation was certainly understandable.

I then inquired about his two medication prescriptions. The first was Amrix^®. When we performed a Google search, we found that the brand-name sustained-release cyclobenzaprine has a monthly cost of $382. I then looked up the price of the branded, immediate-release version, Flexeril^®, and it was about $182. The generic, though, was only $16. The price of medication is something we all need to keep in mind when prescribing for our patients.

I then asked the patient about the acetaminophen/oxycodone he was prescribed. He told me he was having pain and did not want to take the medication because his wife died two years ago from a drug overdose and that he had been drug-free since then. He said there was no way he was ever going to take narcotics again.

I told him that I certainly understood why he did not follow through on his prescriptions and that I was sorry for his loss. I also told him that the healthcare system had failed him. With the patient sitting there, I called the ED and spoke with the treating physician. I told him I was giving him a “F” for his care of this patient.

The ED physician’s response was, “I got the diagnosis right and gave him the appropriate prescriptions. What did I do wrong?” I told him the backstory. He was embarrassed and wondered how many other patients with similar stories he had treated over the past 10 years. He then suggested that we sit down over a cup of coffee and discuss how he could improve his communication skills with patients. Self-awareness and self-management are traits that are difficult to address and improve. When you have an opportunity, like that ED physician, you have to take advantage of it.

Important definitions

Patient-centered care is defined by AAOS as the provision of safe, effective, and timely musculoskeletal care achieved through cooperation between the orthopaedic surgeon; an informed, respected patient (and family); and a coordinated healthcare team.
Source: Farley FA, Weinstein SL: The case for patient-centered care in orthopaedics. J Am Acad Orthop Surg. 2006;14:447-51.

Shared decision making is a process in which the physician and patient exchange information as a means to arrive at a decision about the patient’s preferred treatment. When engaged in shared decision making, the physician is expected to make a diagnosis and “[identify] treatment options according to clinical priorities; the patient’s role is to identify and communicate his or her informed values and personal priorities, as shaped by his or her social circumstances.”
Source: Bernstein J, Kupperman E, Kandel LA, et al: Shared decision making, fast and slow: implications for informed consent, resource utilization, and patient satisfaction in orthopaedic surgery. J Am Acad Orthop Surg. 2016;24:495-502.

Michael R. Marks, MD, MBA, is a member of the AAOS Medical Liability Committee and AAOS Patient Safety Committee, and he is a mentor for the AAOS Communications Skills Mentoring Program. He can be reached at mmarks1988@gmail.com.