Shared decision making

(The following was originally posted on the The AFP Community Blog on 4-22-13.)

Let’s say you’re seeing a healthy 21-year-old woman in your office for contraception management.  She takes no other medicines, has no personal or family history of blood clots, and has no contraindications to estrogen.  She is interested in a long-acting contraceptive that she won’t have to worry about remembering every day.  IUD, subdermal progesterone implant, q 3 months injectable progesterone – how do you choose?

Or, how about this: a 45-year-old man presents with frequent migraine headaches.  You review the best evidence for migraine prophylaxis in adults and are stuck deciding between propranolol and amitriptyline.   Which do you use?

Gray areas like these abound in Family Medicine, even with the ever-growing primary care evidence base.  In both of these scenarios, no one option is clearly superior to the other.  All of those contraceptive options would be efficacious for the 21-year-old woman, and, likewise, the efficacy of propranolol versus amitriptyline for the migraineur is probably a toss-up.

These types of situations, where multiple reasonable treatment options exist, provide an opportunity to involve the patient in the decision.  Shared decision making (SDM) brings the patient’s preferences into the conversation and gives them some ownership over the final choice. 

I wish that I could tell you that SDM has a rigorous evidence base behind it, but like many behavioral interventions, few quality studies exist to suggest patient benefit.  A study last week in the Annals of Internal Medicine, however, may help to reinforce SDM’s value.  Weiner et al engaged patients who surreptitiously recorded their office visits with Internal Medicine residents.  The residents who adapted their care plan to meet their specific patient’s preferences had, in return, improved compliance from their patients. 

This study was small and needs to be replicated in bigger settings, but its finding makes intuitive sense: patients invited to be involved in treatment decisions tend to have better adherence with those treatments.  

You can ease the loss of the extra time it takes to do SDM by billing for the time spent in counseling (10 min = 99212, 15 min = 99213, and 25 min = 99214).  Just be sure to document as such in your encounter note.

In 2010, AFP also published a nice SDM review, along with a helpful framework for the office.  You can find that Curbside Consultation here: http://www.aafp.org/afp/2010/0301/p645.html.

I welcome your thoughts on the practical use of SDM in the busy family doc’s practice.  

Overuse injury

After a three month running hiatus due to the indomitable combination of bad weather (I hate treadmills) and work busy-ness this past winter, I decided last month to pick up my running routine right where I had left off in December.  Two weeks later, with aching ilio-tibial bands and tarsal tunnel syndrome in my left foot, I was forced to stop to allow these overuse injuries to heal.

I knew that I should have started gradually.  Just walked for a week or two, or alternated walking and jogging the first few times out.  But I didn't want to have to wait for my body to re-acclimate to the demands of running.  I just wanted to go.  I readily admit to pushing myself harder than I should sometimes.  Even when I know better, I always want to believe that I am physically capable of more than I am.

Unfortunately, this same tendency creeps up in my work life.  I tend to dive head first into projects without taking the time to think, first, about how big the project might truly be.  I set task deadlines that my brain thinks are reasonable but that I soon discover are impossible.  Despite having lived through these scenarios multiple times, I still keep creating unrealistic "to do" task lists.

List fatigue is the overuse injury of my work life.  And, every time I pile too much on, I am forced to stop, reassess everything, and plug it back into a more realistic schedule.  I hate having to stop working just to figure these things out, just as I hate having to stop running to let IT bands or shin splints or tight hamstrings recover.

I think that ambition and perseverance have many positives about them, but they can be a double-edged sword.  I'm now using a "couch to 10K" app to force me to increase my running time gradually.  I have used this method before with success, and maybe, some day, I'll use it at the get-go next time I have a running hiatus.  I have to admit that my feet and legs are much happier for it.

If only I could find a "couch to work" app, I'd be all set.

Supporting a couple with infertility #NIAW

Before my husband and I joined the 1 in 8 couples in the US with infertility, I don't think that I would have thought much about how to support a friend or family member with infertility.  Not to mention that society's infertility taboo can make these conversations difficult for everyone involved.

Hopefully these resources will make them easier:

I'll start off with RESOLVE.org's great advice: http://www.resolve.org/support-and-services/for-family--friends/infertility-etiquette.html

RESOLVE New England expands on a few of those ideas: http://www.resolvenewengland.org/2013/04/how-to-support-a-friend-or-family-member-with-infertility/

The "I'm Not a Fertile Myrtle" blog gives a more personal spin: http://imnotafertilemyrtle.wordpress.com/2009/04/03/the-dos-and-donts-of-supporting-someone-going-through-infertility-treatment/

This about.com page provides excellent perspective about how to talk about your pregnancy/baby with an infertile friend: http://infertility.about.com/od/familyandfriends/a/10-Things-To-Stop-Doing-If-You-Want-To-Support-Someone-With-Infertility.htm

Scroll halfway down this page from Band Back Together to read "How to Help a Friend with Infertility:" http://bandbacktogether.com/how-to-help-a-friend-with-infertility/.  I really like how this section emphasizes listening to and validating the infertile friend's story.

It is my sincere hope that these "infertility etiquette" resources will help break down the barriers among friends and family that often accompany an infertility diagnosis.