OMR Roundup 9/25/2013

Medical Decision Making

Robin Tang led the discussion this morning about the challenge of making a medical decision in the setting of multiple complex conditions, limited clinical trial data and patient-physician value differences.   We then explored the rapidly expanding field of shared decision making.  Read to the bottom for cool tools to play with!

Case Presentation

Robin mapped out the overlapping issues involved in a treatment decision for a patient with ET, UC, and ovarian failure:

From there, he set about to mapping out a table of risk for each of the treatments in question (aspirin and OCPs):

From this endeavor, we realized that the limitations of available data for specific patient scenarios is limited and that patients have different values for "their QALYs."

Suggested readings:
Robin Tang

How Doctors Think (Jerome Groopman, UCLA Heme-Onc alum)

Thinking, Fast and Slow (Daniel Kahneman)

My addition

Blood journal's "How I Treat" series.  For this case: "How I Treat Essential Thrombocythemia" - based on this study in PV, many recommend ASA for all patients with ET to prevent MI and CVA (in addition to CV RF modification).

Surprise Case - Shared Decision Making

I pulled Saj Patel's case about (discussing aspirin for primary prevention), but he was post-night float!  Amion, you betray me!!!  We discussed shared decision making anyway.

Key points:

• Shared decision making is an interactive process between physician and the patient/family around decisions for which the evidence supports more than one approach, there are significant trade-offs, and personal preferences should drive decisions.  Have you seen the USPTF Grade C?

• We're not sure about the future of shared decision making, but we think it's maybe important.  See the face-off between NEJM and JAMA (published 2 days ago):
• The new Milestones (ACGME requirements) highlight this for residency training: 

(courtesy of SGIM working group ppt)

• Some really cool tools:
• Mayo Clinic Statin/Aspirin Aid  (Main Mayo Shared Decision Site)
  
• Ottawa Personal Decision Guide (for working through generic decisions) 
• Dartmouth Decision Aid Library (click through the links to Tests, Medicines, Treatments for great specific modules for your patients to work though).

Suggested Reading
Your Medical Mind (Jerome Groopman & Pamela Hartzband)