Are You Ready to Engage? (Part Two)

Patient engagement is trending all over the healthcare world, whether we call it “shared decision making”, “patient involvement”, “patient-reported outcomes”, or a number of other phrases. Many studies and book chapters have been written to support the idea that patients generally enjoy better health outcomes when they are more “connected” to the choices and behaviors associated with their care. However, are our direct-care employees ready to engage? Patients come in all shapes and sizes, with different attitudes and expectations, and providers must have the right perspective to be most helpful to those that they serve.

This is the second of several posts that will explore the knowledge and skills that providers will need to successfully engage patients in their care.

Key Idea 2: Not all patients will want to make decisions.

Choosing what to do regarding our health is not as easy as it may seem. Health professionals have contributed many case descriptions of adverse events to the literature that show situations getting out of control very quickly – choices made at one moment can rapidly move through the system, and soon we are unable to stop the error cascade. What’s more, these rapidly-deteriorating events occur despite the knowledge and expertise that doctors, nurses, and pharmacists may possess. Imagine how the gravity of these decisions may look to a typical patient, with limited understanding of biological systems, poor health literacy, and a foreboding fear about what they might be experiencing. They may feel like we have placed them behind the yoke of a 777 with little more than a crash course in how to move the rudder. They may be overwhelmed with variables, possibilities, and potential mistakes, and probably have no reliable way to navigate through it all.

Of course, this doesn’t mean that shared decision making (SDM) is a bad idea. “Nothing about me, without me,” as Lucian Leape is fond of saying, simply means that health care professionals must remember that people are people, not projects, disorders, or inanimate objects, and they can contribute to their care. But it is beyond this point that uncertainty sets in. We cannot assume that patients have been waiting for doctors, nurses and pharmacists to stop telling them what to do and start letting them make their own decisions. We cannot assume that every patient wants the control we may be offering.

Psychologists have long discussed the elemental nature of control in human behavior. Generally, individuals will vary in two ways regarding control: 1) how much they think they have, and 2) how much they really want. Control is often expressed by our choices as we attempt to create the world we want. When a patient like the one described above considers control and choice in the context of their own health, they are asking two fundamental questions. Will my choices really make a difference? Do I really want the burden of telling the doctor what I want? I would argue that many patients see the doctor’s office as the place to get answers and be told how to fix whatever is wrong. They believe that they are buying knowledge, expertise and solutions. They are keenly aware of the chasm separating what they know from what the doctor knows, and they will be hesitant to believe that they can make a decision as accurately. This is the real battle in SDM – offering patients control and choice without offering them too much. Many believe that having choices is always motivating, but research in psychology demonstrates that this is not always accurate. Sometimes the ability to choose is not only demotivating but frustrating and confusing.

In light of these ideas, I encourage health care professionals to follow the guidelines below.

  1. Ask your patient how comfortable they are with the idea of SDM before doing it.
  2. Let the patient practice the new role you are offering using a less important decision as practice.
  3. Come to a clear agreement with the patient about who will make the final decision on their care for each individual decision.
  4. Explain that it is OK for the patient to give you permission to decide.
  5. Remember that patients who are under considerable stress will be less able to choose from a lot of options.
  6. Be vigilant for signs of psychological strain (anxiety, irritability, flat emotions, apathy) as these strains will reduce the patient’s capacity to participate in SDM.

Are you ready to engage?