Exploring the power of shared decision making to improve care

By Beth Negus Viveiros
November 1st, 2024
talk-therapy

Listening closely to patients’ concerns and using shared decision making that is consistent with a patient’s personal values and goals can improve the quality of care given by both psychologists and physicians. This is particularly important when treating marginalized populations, according to Pennsylvania-based psychologist Aviva Gaskill, Ph.D.

“This is a tool that we can use to promote health equity,” said Gaskill in the recent webinar “Invisible Disabilities, Intersectional Identities, and Healthcare Disparity: What We Can Do About It, Including Ethical Considerations,” part of the Connecticut Psychological Association’s Social Justice Speaker Series.

“It [can offer] a really important insight on why people who are marginalized are some of the most vulnerable, and yet the least likely to receive adequate care.”

When dealing with patients who have invisible disabilities, shared decision making can make a significant impact, she said. Invisible disabilities are physical, mental, or neurological conditions that are not visible from the outside, but can still limit or challenge a person’s movements, senses, or activities.

Examples include fibromyalgia, multiple sclerosis, neurodivergence, or diabetes.

“Shared decision making is actually linked to less patient transfer and greater patient satisfaction,” Gaskill said. “It makes sense, and so it’s really helpful to reduce health inequities. Physicians who practice shared decision making incorporate personal values, needs, narratives, and preferences of the patient into decision making about the different interventions [available].”

Shared decision making has a three-step model, said Gaskill:

1. Choice Talk: Providers inform patients of the choices that are available, provide justifications for each option, and check the patient’s reaction.
2. Option Talk: Providers check the patient’s knowledge, list the options available, give more detailed information, and summarize.
3. Decision Talk: Providers collaborate with patients to consider preferences, support the patient in their decision making, and review decisions.

“This is what we do a lot as psychologists,” she said. “We say to the patient, ‘you know yourself best, you know your symptoms best, you tell me.’ It’s the number one in our work, and it needs to be number one when a physician sits down with someone too.”

Intersectionality — the interconnected way that social categorizations such as gender, race, ethnicity, sexual orientation, gender identity, disability, or class — can overlap to create unique or amplified dynamics, which can also negatively impact the quality of care patients receive. This is because medical professionals often zero in on one aspect of a patient’s identity, and ignore their concerns, Gaskill said.

As an example, Gaskill cited one patient who is in a bigger body and has several chronic medical issues.

“She said to me ‘I know when I go to my primary care doctor, they are going to forget about all my disabilities, and they are going to look at how fat I am. They are going to judge me and talk about that, and it will override everything I need from them,’” she said. “I told her I know you are frustrated by this, because [it happens] every single time.”

There are several things that psychologists and physicians can do to improve healthcare equity for individuals with invisible disabilities and intersectional identities, by making it easier for them to understand their options, including providing:

• Sign language interpreters for those hard of hearing
• Staff trained in disability awareness to facilitate communication
• Educational materials in Braille for the visually impaired
• Documentation in larger font sizes or reverse type
• Visual aids such as pictures and diagrams to supplement written or verbal materials

Numerous factors contribute to healthcare inequity. The Commonwealth Fund 2024 State Health Disparities Report revealed that racial and ethnic disparities in access to care, quality of care, and health outcomes were prevalent in every state. For example:

• On average, Black people are more likely than Asian American, Native Hawaiian, and Pacific Islander (AANHPI), Hispanic, and white people to die early from avoidable causes.
• Breast cancer is more likely to be diagnosed at later stages among Black women, who have much higher age-adjusted death rates for the disease than other women in most states.
• In most areas of the U.S., infant and maternal mortality rates are highest for Black and American Indian and Alaskan Native residents
• Hispanic people have the highest uninsured rates and cost-related problems in getting care.

Gaskill noted that another variable that adds to healthcare inequity is the fact that healthcare facilities are often concentrated in certain areas of the country, and therefore inaccessible to segments of the population because of location and/or cost.

“The areas with the need for high-level trauma centers are not necessarily where those centers are located,” she said.

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