Shared Decision Making and Agreeing to Disagree

Early in my career as a preventive cardiologist, I learned the ACC/AHA Adult Treatment Panel III guideline inside and out. This guideline was more complex than most, combining LDL cholesterol levels with risk calculations in a matrix that determined treatment thresholds. I published an article in Circulation mapping the U.S. population to this matrix.

Jon Keevil, MD
CEO and Founder, HealthDecision

In those early days, I put great energy into calculating patient risk, identifying cholesterol levels, and then expressing my well-informed opinion on whether to start a statin medication. If a patient disagreed with my assessment, I would lean into my expertise and work to convince them to agree to the treatment path I had laid out.

Agreeing to Disagree with the Patient

With time and experience, however, my approach to patients who disagreed with my assessments became more balanced. For these patients, I asked their permission to explain my reasoning and used the opportunity to teach what I knew about the topic and what led to my recommendation. If they understood my reasoning and still didn’t want to take my recommendation, I accepted their position, and we agreed to disagree. Patients would also share their own views and values giving me insight into what was important to them.

The HealthDecision tools can make this interaction even easier. The tools display the recommendations from national clinical guidelines, but then take the discussion another step, showing the impact of one therapeutic choice compared to another. For example, the ACC/AHA guideline recommends considering a statin for someone above 7.5% risk of a cardiac event. Beyond that one threshold, the tool illustrates the absolute risk reduction of a particular statin. By sharing this tool with my patient, we are starting with the same information, so even if we disagree, I have greater confidence that the patient understands the science. Using the tools, the clinician and patient can engage in true shared decision making where both the science and the patient’s values can meet. In these situations, agreeing to disagree can be a very comfortable process.

Agreeing to Disagree with the Guideline

There is an additional nuance to shared decision making that the tools can support. At times, a guideline and a particular patient will not match very well. For example, a 66-year-old male, even with an LDL-C of 80, can easily reach an ASCVD risk over 10% and be appropriate for a statin conversation. However, the HealthDecision tool will illustrate the very limited benefit available from a statin prescription with such a low baseline LDL cholesterol. In this case, the HealthDecision tool supports the clinician and the patient agreeing to disagree with the guideline itself.

Now with the experience of hundreds of clinicians supporting thousands of patient decisions, HealthDecision has shown a strong correlation between use of these shared decision making tools and improved patient satisfaction, and clinicians observe greater patient trust. Presenting better data in a better way to both parties in the discussion makes for better decisions by many measures.

2017-06-08T09:04:42+00:00 May 5th, 2017|