Shared decision making andAustralian general practitioner training

Dr Ronald McCoy, Education Strategy Senior Advisor, Royal Australian College of General Practitioners

Are general practitioners trained in shared decision making?• General practitioners in Australian are

trained according to the Royal Australian College of General Practitioners (RACGP) Curriculum for Australian General Practice.

• Challenge for curriculum development is to:• incorporate relevant attributes, skills

and knowledge each of these into general practice training in a co-ordinated fashion to meet the health needs of the Australian community.

• Also sets the agenda for lifelong learning including continuing professional development

Diversity of general practice• GPs have to deal with a

wide range of health problems

• Reviewed every three years • Currently undergoing review• Stakeholder consultation for

in the next few weeks• Will be available for

comment for about 2 months.

• Provides an important opportunity to review the role of shared decision making in the curriculum.

Shared decision making in general practice“Shared decision making is the process of clinician and patient jointly participating in a health decision after discussing the options, the benefits and harms, and considering the patient’s values, preferences, and circumstances.”1

 Historically:• Australian general practice and general

practice training has a long history of patient centred community

• Until recently, general practice has not been seen as a place of research, yet this is where the majority of the health care in the community occurs

• Resulted in a disconnect between evidence based medicine and the clinic, where the majority of people are treated within the community

• The role of this evidence base is key for implementing shared decision making for optimal patient care 

 1. Hoffman TC et al. JAMA 312:1295

RACGP Curriculum and shared decision makingShared decision making does appear in the RACGP Curriculum in two

ways:• Explicit: as “shared decision making”

• Quality use of medicines, Chronic disease• Use negotiation and problem solving skills in shared decision

making with• patients from culturally and linguistically diverse backgrounds.• Women’s health

• Implicit• Shared decision making skills without being named• Attributes, skills, knowledge behaviours for shared decision

making

RACGP Curriculum and shared decision making“Shared decision making is the process of clinician and patient jointly participating in a health decision after discussing the options, the benefits and harms, and considering the patient’s values, preferences, and circumstances.” 1

 

1. Hoffman TC et al. JAMA 312:1295

 Definition

 Training outcome examples from RACGP Curriculum for Australian General Practice 

 Shared decision making … 

 Patient-centred skills

 Evidence-based medicine skills

 is the process of clinician and patient jointly participating in a health decision…

Demonstrate respect for patient autonomy. Work in partnership with the patient as determined by the needs

of the patient. Negotiate patient centred management plans that consider the

patient’s preference of treatment and priority of treatments. Use communication skills to underpin effective diagnosis and

management of the patient (eg. listening, reassuring, explaining, interpreting).

Use communication skills to build and maintain a therapeutic relationship between patient and doctor.

Communicate the evidence for management, diagnosis or screening to patients in a manner that is both understandable to the patient and is patient centred.

Involve the patient in the evidence based decision making process about their health and acknowledge the informed patient’s right to choose to accept or decline new interventions based on research evidence.

Have well developed skills in reflective practice and critical thinking in order to identify and formulate questions as they arise in clinical practice

 

after discussing the options, the benefits and harms,…

Use problem solving skills to collaborate with patients on acceptable management plans.

Integrate scientific evidence and other relevant factors when problem solving.

Integrate scientific evidence and other relevant factors when problem solving.

Have sound skills in critical appraisal of different types of evidence sources.

and considering the patient’s values, preferences, and circumstances

Have a holistic perspective, taking into account the patient’s social, psychological, cultural and existential dimensions.

Elicit and take into account a patient’s sociopolitical, economic, work, spiritual, linguistic and cultural background and needs, as well as their relationships with family and significant others in relation to their health.

Be aware of and use, where appropriate, relevant written materials.

Understand how educational background and literacy levels may be difficult to assess when there is a language barrier.

Understand that the relevance of educational materials will vary for each individual, eg. some people speak one language but read in another – this will have implications when determining which resources are appropriate for the patient.

Be aware of the impact of a patient's own cultural lens. This includes beliefs about disease, health and healthcare; the impact of faith and religious beliefs; and pharmacology differences in different ethnicities.

Challenges for incorporating shared decision making into general practice training - 1

Efficacy of shared decision making approaches• Ensure having good methods and processes are taught

to GPs• having sufficient evidence, tools and guidelines for the

diversity and generalisability of general practice settings

• GPs have a lot of experience with using clinical guidelines, but perhaps less with decision making tools

Application of methods• ensuring that share decision making situations are

identified• processes are implemented for each situation

Challenges for incorporating shared decision making general practice training - 2

GP attitudinal barriers (highly variable!)• “I already do this”• “I don’t feel confident too…“• “I do not enough time to..”• Makes patients anxious by increasing uncertainty • patients just want to be told what to do• Most people don’t know how to participate in shared decision

making• Some patients may find this difficult to negotiate eg patients with

disabilityPatient barriers• Cultural eg patients form doctor centred cultures• Health literacy  

 Challenges for incorporating shared decision making general practice training - 3

Accessibility • Ensuring diversity of access of benefits of shared decision

making • GPs treat the entire community• Shared decision making involves issues of empowerment

• Need to involve advocates and consumers in women’s health, multicultural health, Aboriginal and Torres Strait Islander health etc. when developing shared decision making processes

• Issues for those in rural and remote areas• Accessibility of support materials e.g. decision making

tools

Summary: shared decision making and general practitioner trainingShared decision making:• has many benefits for optimising patient care in the general practice setting• has made some inroads into general practitioner training, but needs to be

strengthened in general practice training, • Needs to be strengthened in in the RACGP Curriculum for Australian

General Practice• Good news: Not starting from scratch

• There is already a strong skill base is there• Rise of teaching of critical thinking and research skills in medical

schools• Increased availability of decision making tools

Also need to look at what supports for need to be developed for the implementation of shared decision making into general practice training.

RACGP Curriculum Review

All contributions are welcome• Please contact the RACGP is

you would like to provide input into the next RACGP Curriculum for Australian general Practice

• Place you on the stakeholder list• Also tell your colleagues and

other organisations• Open to all organisations and

the entire community