Choices and Changes

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From the Classroom to the Clinic
Shared Decision Making
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• J. Gregory Carroll, PhD

Bayer Institute for Health Care Communication
555 Long Wharf Drive, 13th Floor New Haven, CT
06511-5901 800-800-5907 www.bayerinstitute.org
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Benefits of Change

• Patient Improved health status
• Clinician Increased satisfaction
• Health System Reduced costs
• Family and Friends Greater availability
• Work Increased productivity

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CONCEPTS
Stages of change
IDENTIFICATION
Source Prochaska DiClemente
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People dont adhere
CONCEPTS

• 30 to 40 of all patients fail to follow
  preventive regimens
• 20 to 30 of all patients fail to follow curative
  medication regimens
• 50 of all patients on long term regimens fail to
  adhere
• 50 of all patients requiring life style changes
  fail to adhere

(Hayes et al, 1979 DiMatteo et al, 1994 Clark
Becker, 1998)
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CONCEPTS
High
10
Convinced
Stuck frustrated
Moving helping
Conviction
Stuck skeptical
Stuck unaware or cynical
0
Ambivalent
Helpless
Powerful
Confidence
High
Low
0
10
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The clinician is the intervention
CONCEPTS

• Key elements
• Ask before tell open-ended inquiry assess
  conviction and confidence
• Build rapport reflective listening, empathic
  communication
• Tailor the method to match the patients
  conviction and confidence

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Ask the patient to quantify
TECHNIQUES

• On a scale of 0 to 10, how important is it to
  you to make this change?
• On a scale of 0 to 10, how confident do you feel
  that you can make this change?

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Enhancing confidence
CONCEPTS

• Assist the patient to
• Recall times when she/he has been successful
  making changes
• Make a conscious, deliberate choiceto make the
  change support the patients autonomy
• Move away from an either/or frameof mind

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Enhancing confidence cont.
CONCEPTS

• Assist the patient to
• Define steps that are likely to lead to
  success
• Attend to progress and to perceive slips as
  occasions for problem solving rather than as
  failure
• Ask the patient For your confidenceto move
  from a 2 to a 4 on a scale of 10,what would have
  to happen?

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Enhancing conviction
CONCEPTS
Provide new information when it is relevant. Ask
the patients permission

• Assist the patient to
• Illuminate the discrepancies between goals and
  actions
• Discover the normal conflicts of values which
  lead to ambivalence

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Enhancing conviction cont.
CONCEPTS

• Assist the patient to
• Clarify a values hierarchy
• Identify optional reward systems
• Ask the patient For you to become more
  convinced that this change is in your best
  interest, say from a 2 to a 4, on a scale of 0
  to 10, what would have to happen?