According to research, time is a scarce, but vital, element of shared decision making for both patients and clinicians. The importance of time was also demonstrated in an investigation by Arwen Pieterse, PhD, and in her work conducted at the department of biomedical data sciences, Leiden University Medical Center, The Netherlands.1
In a recent article in JAMA, Dr. Pieterse and colleagues say uncertain evidence and a patient’s unique healthcare issues can make it challenging to identify the best course of care—especially as people live longer with multiple chronic conditions.2 Added to this challenge is the fact that a lack of time is consistently identified by both physicians and patients as the most common barrier to shared decision making.3,4
A Closer Look at Time with Patients
As a first step toward a different way of thinking about time spent with patients, Dr. Pieterse suggests rheumatologists think critically about their time invested in clinical activities and patient encounters.
“Use time if, and when, it is helpful,” she says. Dr. Pieterse suggests rheumatologists take three step to be more strategic with clinical time:
- During a patient visit, discuss how often they really need to come to the office for follow-up visits and what lab testing is appropriate to inform healthcare-related decision making. Try not to make clinic visits and lab testing into a routine that doesn’t add to the patient’s health and wellbeing;
- Before a patient consultation, consider what management options best fit the patient’s situation and the relevant information to discuss about the benefits, harms and procedures related to their options; and
- Make it a habit to give patients time before making a decision. It can be valuable to allow the information to sink in for the patient, enabling their preferences to emerge. Many healthcare decisions are new, even for patients with chronic conditions. Their condition may worsen or improve, or the patient may suddenly have become intolerant to a treatment they’ve been on for a while. When such new situations emerge, they require a renewed consideration of the patient’s priorities, goals and preferences. More time by itself can be helpful for this clarification process.
Give Patients Time to Think
Although she isn’t aware of practices in which the schedule of the clinician does not determine the time available for a patient, Dr. Pieterse points to ongoing studies in the Netherlands in which a timeout is offered to patients during or in between clinical encounters. The time-out aims to provide patients with time between becoming informed of their options and making a decision.
“We know clinician–patient exchanges become more interactive when clinicians ask open questions and allow silence, so that patients are encouraged to provide their views [rather than just saying yes or no],” Dr. Pieterse says. “A key characteristic of this encounter is for the physician to be curious about this individual patient and motivated to learn more about this patient’s situation, needs and desires.”
Some clinicians and rheumatologists may question the value of re-evaluating the schedule and format of patient encounters to encourage more effective decision making and connection. Often, clinicians say there is no time for involving patients in decision making, but Dr. Pieterse asks what is it for which there is too little time? Only if rheumatologists have insight into when time is lacking and for what it is lacking will they be able to create time that will effectively involve the patient, she says.
“Rheumatologists need to become clear on the situations and cases in which they would really want the patient to be involved, and then find out when time is too short and when time can be saved,” Dr. Pieterse says.
This approach doesn’t mean a rheumatologist’s workload should be transferred to the patient, she notes. Example: Some practices have patients prepare for a visit by reading information ahead of time, so the clinician does not need to explain it. This approach may be helpful, but may not be a patient-centered approach.
Dr. Pieterse says, “Understanding the situations in which more or less time is needed with clinical encounters means physicians and their patients work to understand how time could be better distributed over the decision-making process.”
Carina Stanton is a freelance science journalist based in Denver.
References
- Bomhof-Roordink H, Fischer MJ, van Duijn-Bakker N, et al. Shared decision making in oncology: A model based on patients’, healthcare professionals’ and researchers’ views. Psychooncology. 2019 Jan;28(1):139–146. Epub 2018 Nov 8.
- Pieterse AH, Stiggelbout AM, Montori VM. Shared decision making and the importance of time. JAMA. 2019 Apr 19.
- Joseph-Williams N, Elwyn G, Edwards A. Knowledge is not power for patients: A systematic review and thematic synthesis of patient-reported barriers and facilitators to shared decision making. Patient Educ Couns. 2014 March;94(3):291–309.
- Légaré F, Ratté S, Gravel K, Graham ID. Barriers and facilitators to implementing shared decision making in clinical practice: Update of a systematic review of health professionals’ perceptions. Patient Educ Couns. 2008 Dec;73(3):526–535.
