By Terri Coutee and Minas Chrysopoulo, MD FACS
I feel very passionate about opportunities to educate others on the topic of shared decision-making. Shared decision-making is when the patient and physician work as collaborative partners in deciding a treatment plan that is best for the patient. After recording a ZOOM interview with Dr. Minas Chrysopoulo recently, the topic came up as it often does. Dr. C said to me, “Let’s write about it together.” It took no time for me to agree to co-author this blog!
What Shared Decision-Making is NOT…
As a patient advocate for all options of breast reconstruction, I have the opportunity to speak to others who are planning or recovering from all types of reconstruction. I ask if they felt fully engaged in their decision process for their reconstruction. It is apparent to me that they were NOT when they tell me they were not even presented all of their options for breast reconstruction. Even though most women choose implant-based reconstruction, there is a growing number of those who want to use their own tissue, like I did and have DIEP flap.
Not being given all their breast reconstruction options does not allow the patient to make a fully informed decision. The choice to reconstruct or not, and then the type of reconstruction a patient ultimately chooses is such a personal decision. By definition, when a surgeon does not offer the patient a procedure they may want to consider, whether that procedure is something in their skill set or not, a shared decision-making discussion cannot take place.
If a surgeon is highly skilled in implant-based reconstruction, but does not frequently perform autologous tissue reconstruction, the patient should still be told about the autologous options available to them. I understand and appreciate that in a fee-for-service system, like the ones we have in the US, some surgeons may be fearful of “losing the patient” to another practice. However, if the best interests of the patient are to be prioritized, they should be offered an addition consultation with a colleague who frequently performs autologous reconstruction, if the patient is interested in learning more.
Shared decision-making should be considered a meeting of two experts. The patient is the expert on what’s important to them: their values, preferences, other things going on in their lives, support structure, what they need to get back to…the list, like the patient’s final decision, is a very personal one. The surgeon is the expert at presenting all the choices, risks, and benefits of the surgery. Each team member in this collaboration must listen carefully to the input from the other to allow for the “best-fit” decision to be made.
Dr. C made a rather poignant statement in our off-camera discussion on the day of our ZOOM…” If the surgeon doesn’t consider the patient’s input before making a treatment recommendation, they probably don’t practice shared decision-making”.
Dr. Chrysopoulo on Shared Decison-Making
A recent study (https://jamanetwork.com/journals/jamasurgery/fullarticle/2671391) showed that 57% of patients feel they did NOT make a “high quality” decision concerning their breast reconstruction choices. A big part of the problem is that decisions tend to be made in a short time and often in the context of strong negative emotions. Without considering what is most important to the patient, it is impossible for surgeons to adequately address expectations regarding outcomes after each procedure.
Without appropriate expectations, patients are much more likely to be unhappy with the results of their procedure and suffer decisional regret. Shared decision-making prevents this cycle by placing the patient’s preferences and values at the center of the decision-making process. Multiple studies throughout various medical fields have shown shared decision-making improves patient outcomes and satisfaction.
Shared decision-making can also be quite rewarding for the physician. Not only is it an effective and ethical way to interact with patients, it creates the opportunity to deliver more patient-centered care. While some treatment options or procedures may have proven advantages in certain clinical situations, there is often no universal ‘best’ choice and as doctors, we must acknowledge that patient needs and wants can vary tremendously. Physicians must be willing to acknowledge and consider patients’ personal values and preferences while assessing and discussing what is medically appropriate and reasonable. In doing so, shared decision-making not only improves patient satisfaction and outcomes but is also an effective and ethical approach in ensuring patient goals are met whenever possible.
While shared decision-making should be standard practice, unfortunately it is not standard practice. An important factor here is time. Many patients feel they don’t have enough time to process all the information and can feel they are being rushed into making a decision. In addition, some physicians, through no fault of their own, simply don’t have adequate time to allow for a shared decision-making conversation with every patient. This is where decision aids like the Breast Advocate App are invaluable.
Shared Decision-Making Aids
Breast Advocate educates users in a comprehensive and personalized way about all their breast cancer surgery and reconstruction options, and also provides access to the latest studies and expert opinions. Patients can take as long as they need to go through and process all the options in the comfort of their own home. This also enable patients to spend the time with their surgeon(s) focusing on specific details rather than general information.
I would like to express my personal gratitude to you, Dr. C, for giving your time to co-author this blog. You taught me the value of shared decision-making, Kind Sir. The Journey continues as we educate about this important topic.
You are exactly correct. My PS told me the options. I do not think he addressed diep. I know he talked about tram flap. Talked about removing a muscle and long recovery time. I asked him if he could do a abdominoplasty with the implant surgery he said no could do it at a later time. At that point he should have suggested I consider diep. But he is not a microsurgeon.
Thanks so much for sharing your experience, Heather. I do hope patients will continue to be offered all their options, no matter what type of breast reconstruction they choose. ~ Terri