Thursday, 4 December 2014

Decision aids and option grids in undergraduate teaching

Communicating evidence to patients

There are always obstacles to using best research evidence with our patients to help them make decisions that are right for them. One of these is the actual conversation and decision-making process we engage in with patients. Assuming we have identified research to help quantify the relative benefits and harms of different treatments how do we communicate these? Given that dentists themselves often struggle to use the data they encounter, what hope is there for our patients?

Integrate evidence into practice

My driving force in the programme of evidence-based dentistry that I have developed and sought to integrate in the 5 year undergraduate dental programme at Queen Mary University of London is that evidence has to be taken beyond critical appraisal and incorporated into the clinical decision-making process. As the students enter their third year and find themselves on clinic, engaging with patients in discussions about treatment options, therefore, seemed like the ideal time in our new curriculum to get them to move their learning about EBD in years one and two onto the clinic.

Shared decision-making

The concept of evidence-based practice for me is one that integrates our own clinical experience, the research and the values of our patients. These are made within a particular context that either facilitates or prevents the use of best evidence (limited resources on the part of patients or the healthcare system will always limit what is actually available). Shared decision making is an approach to care that involves communicating the probabilities of positive and negative outcomes associated with different management options (including doing nothing) (Ref). So how do we communicate the risks and benefits of different treatment options in a relatively objective way?

Decision aids and option grids

There is now quite a large body of research looking at the use of decision aids (Ref) that suggests they can improve several aspects of the decision-making process for patients. From this recent Cochrane review:
"There is high-quality evidence that decision aids compared to usual care improve people's knowledge regarding options, and reduce their decisional conflict related to feeling uninformed and unclear about their personal values. 
There is moderate-quality evidence that decision aids compared to usual care stimulate people to take a more active role in decision making, and improve accurate risk perceptions when probabilities are included in decision aids, compared to not being included.
There is low-quality evidence that decision aids improve congruence between the chosen option and the patient's values."

Engaging undergraduates with decision aids

So we got our third year undergraduates to create their own decision aids relating to various clinical scenarios using the best available research they could. Sometimes this means there was systematic review level evidence to help, for others it was at the level of primary studies. We then had them role play using the decision aids with "patients" (this year it was fellow dental students but we plan to employ actors next year). An example of an option grid (see a brief video describing these below) is here:

The process of using these aids in their discussions with the patients seems to have really caught hold. The ease of use - and confidence it gave them in being able to demonstrate the evidence - were seen as very positive.

We had the students in one seminar not give the decision aids they created to their patients beforehand and in the others they did. By the "patients" reviewing the aids beforehand created a very different dynamic that was led much more by the patients' concerns as they picked up the issues they felt were most important to them and the dental student could then explore these in greater detail.

There is a really nice video showing how option grids (very similar to some decision aids and what most of the students created) can be used here:

What is great is that the day after the seminar students were using their option grids with patients they saw on clinic. Now that's getting evidence into practice!

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