No Easy Answers in Bioethics Podcast

Shared decision-making in medicine: Barry and Holmes-Rovner - Episode 2

October 12, 2017 Henry BarryMargaret Holmes-Rovner

Dr. Henry Barry, Professor in the Department of Family Medicine and Senior Associate Dean for Faculty Affairs and Development in the College of Human Medicine, and Dr. Margaret Holmes-Rovner, Professor Emerita in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine, discuss their often-overlapping and collaborative work in the areas of shared decision-making and evidence-based medicine. They reflect back on how they got started working in these areas at Michigan State University in the 1980s, and provide insight on where things currently stand.

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: "While We Walk (2004)" by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License.

Related Publications

  • Holmes-Rovner M, Srikanth A, Henry SG, Langford A, Rovner DR, Fagerlin A. Decision aid use during post-biopsy consultations for localized prostate cancer. Health Expectations. Epub 7 Sept 2017. DOI: 10.1111/hex.12613.
  • Stacey D, Légaré F, Lewis K, Barry MJ, Bennett CL, Eden KB, Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Thomson R, Trevena L. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews 2017, Issue 4. Art. No.: CD001431. DOI: 10.1002/14651858.CD001431.pub5.

Episode Transcript

Liz McDaniel: Hello and welcome to another episode of No Easy Answers in Bioethics, the podcast from the Center for Ethics and Humanities in the Life Sciences at the Michigan State University College of Human Medicine. Today we are joined by Dr. Henry Barry, Professor in the Department of Family Medicine and Senior Associate Dean for Faculty Affairs and Development, and Dr. Margaret Holmes-Rovner, Professor Emerita in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine. Dr. Barry and Dr. Holmes-Rovner discuss their often overlapping and collaborative work on both shared decision-making and evidence-based medicine, and they provide insight into where we've been, what we've learned, and where we're headed in the future.

Margaret Holmes-Rovner: I’m Margaret Holmes-Rovner. I'm Professor Emerita of health services research and ethics in the Center for Ethics. I've been at MSU since 1980 and I'm still research active here.

Henry Barry: Hi Margaret, I'm Henry Barry. I am a professor in the Department of Family Medicine here in the College of Human Medicine and I've been here since 1989. In the last couple of years I have served as the Senior Associate Dean for Faculty Affairs and Career Development.

MH-R: Okay and I think we're… we're here to, um, talk about our career long activity. Me in shared decision-making and you in evidence-based medicine.

HB: Yeah, it's good for us to get back together again. We've worked off and on over the years and I… I miss having you around in my life on a regular basis.

MH-R: That's true we've collaborated on some articles and certainly on some projects of… of mutual interest. So, I was reflecting on, um, kind of where… how I got to be relatively prominent nationally and internationally in shared decision-making and I've come… and I want to tell you a couple stories that go back to the 80s, I mean one thing obviously is to do good research and get funded and write, but that's not really the whole reason at all that, um, some of my activities came together in there. They had to do with building teams and with collaboration. Um, and you know, I was lucky enough to be hired into Arthur Elstein’s research group in medical decision making which may have still been going when you were here…?

HB: In 1989, he had already retired.

MH-R: Okay.

HB: When I was doing my residency here in town from ’82 to ’85, he was still around.

MH-R: Oh right.

HB: Yeah.

MH-R: Okay. So…

HB: He came to campus a few times in the late 80s and early 90s to do some follow-up consulting.

MH-R: Oh okay. So you remember his interest in clinical decision analysis, as well as descriptive work on how doctors make decisions.

HB: Yes.

MH-R: Yeah, so I was lucky to join that group, um, and was hired into a grant, a program project grant from the National Library of Medicine which had four different cases of to describe how doctors make decisions and to compare them to the rational models that he had come to know through the clinical decision analysis stuff. Um, but so how did … where did you get started with evidence based medicine?

HB: Well, you know I've always been a bit skeptical, I've always been a self-directed learner where I would just try to figure out what are the things that I need to know and then find answers independently. And that level of independence and skepticism was really enhanced by Jack Pascoe, who was a pediatrician here in Lansing back in the 80s, when I did my residency. He would host these journal clubs and the journal clubs I was exposed to as a student was “oh here's what the article says and let's go do that,” well Jack actually challenged that approach which really fed into my skepticism. You know not everything that's published in The New England Journal is true and that was like “oh my gosh!”

MH-R: (laughs)

HB: So … so that was … that was the first time I was exposed to academics really challenging at a foundational level the quality of the underlying research. Not the questions or who they studied but whether or not they actually got it right. So from there I continued my training I practiced for four years in Appalachia got, um, really enmeshed into caring for people and becoming fairly pragmatic. And then when I came to MSU as a faculty member, I had an opportunity to get some additional training and so I got a master's program in clinical research design and statistics, which helped me with asking better questions, thinking about how to design better ways to answer the questions that I had inherently, but it also reinforced some of the skills that Jack Pascoe tried to train which was that you know there is a right way and a wrong way to do research and that in the real world sometimes you have tradeoffs. So that was really to me the night as was … was Jack.

MH-R: Yeah and for me the same kind of skepticism and you know we were- had … I was trained as a qualitative sociologist and then I came into this research group when … when we were really just beginning nationally to think about what do the rational models suggest that people should do, as well as just what, um, what do they do and how … how do they learn it from their peers. So as you know the Society for Medical Decision Making was full of such skeptics and people who were in love with clinical decision analysis and cost effectiveness analysis. So here's the story that there's the networking story that I enjoy telling because it really is the beginning of shared decision-making, having an international presence, and what happened was, um, through, um, the 80s, I had in the Society for Medical Decision Making had got to know Hilary Llewellyn-Thomas, who was a researcher at … um, in Toronto at the University of Toronto and Annette O'Connor who was at Ottawa, among other people. And so in 1999, um, my favorite colleague and husband David Rovner and I met up with Hilary and, um, Annette at the International Society for Technology Assessment in Health Care. And ISTAHC was being held in ‘99 at Edinburgh Castle and the four of us were going to Edinburgh Castle, and I … I went into them and I said, you know we've learned so much in the last fifteen years of doing research, almost twenty, that we've reported at SMDM and other places, why don't we do a sabbatical together? What would you think, we'll write a book, and they said “oooh that sounds like fun.”
So I said okay I'm looking for a sabbatical, I'm going to my … I’ve already been to London and talk to Angela Coulter at The King's Fund. I'll find Angela and see what she thinks of perhaps hosting us in Oxford. And they said “oooh that sounds like fun go for it,” so I was looking for Angela and, um, Edinburgh Castle the organizers of the meeting had spent a whole lot of money on bagpipers and wine but not a whole lot of money on food.

HB and MH-R: (laugh)

MH-R: So we were all very hungry in the place … the little place where the food was getting very crowded but I did find Angela and I said Angela I've talked to Hilary and Annette and we think we'd like to write, um, a book about what we've learned about patient values, patient utilities, physician decision-making, and how these fit together and form the basis for shared decision-making and for evidence that we can give to patients and give to clinicians that will help them make better decisions. Well she got very excited and said, “oh if you're going to do that,” she said “I have a phone call waiting for me in my hotel, with a request to start a branch of the Picker Institute and I'm going to start it in Oxford and if you'll do that, I'm going to say yes, we’ll … I'll do … I'll start Picker and the … you all can come and we'll start … we'll do work together. Which we did. We spent six lovely months, we all shared an apartment in Summertown in-- near Oxford. And we wrote a couple of articles and we thought we'd done great work. But then as we were about to leave, the … the English do a lot of things over dinner, so we were having dinner and Muir Gray, who was the director of the Institute for Healthcare there in Oxford, turned to me and he said, “well that's fine, you've been here for six months and talked to us. But you need to broaden the conversation. How are you going to spread … spread the word about shared decision-making?” So, I thought about it overnight and I thought, oh okay, we'll have an international meeting and we'll have a listserv.
Just having the idea gets it done, right? I was fortunate enough that the first meeting of the European Association for Communication and Health Care, EACH, was going to be held at Oxford and they'd already booked it the next summer. And after many hours of negotiations, um, they gave us a track in the EACH meeting and we kicked off the shared decision-making international meetings which have been held every two years since 2001.

HB: That’s great. (laughs) So I have a comparable story as a master’s assignment. We were supposed to do a decision analysis. We had many things as part of the master's program, but that was just one of our assignments. And I had the chance to work with two family physicians, uh, colleagues who eventually became colleagues. John Hickner and Mark Ebell and we collaborated on this decision analysis. We decided actually we're going to do a cost utility analysis, we're going to do more than what the teacher requested. And as family physicians grounded in some pragmatism, we decided to take a common everyday problem, hopefully… yeah I guess it is every day, that many women are afflicted with that's urinary tract infections. And we went to the literature and we decided to, uh, actually do a cost utility analysis comparing many different strategies. And as a result of that, we ended up with some national presentations, some workshops that we did on cost utility analysis methodology, the manuscript. As a result of the … the presentations we got a chance to understand … hear that the National Institutes of Health were just in the process of developing their, uh, their sentinel work on standardizing methodology around this. So we got a chance to meet Marthe Gold and she was very, um, encouraging of this. So the three of us ended up developing a whole series of things as a result of this. Including, um, a spin-off of … of the project, which was the first randomized trial of telephone management of anything. And we learned that this was actually a common approach we just didn't know whether or not it was worth doing or not. And so … so that just led to a whole series of activities. And then Mark and I met Dave Slawson and Allen Shaughnessy who had developed this conceptual framework around evidence-based medicine, that was really much more practical for the averaging … average practicing physician. They called it information mastery. And at its core was a usefulness equation that the usefulness of any information that somebody might use, is directly proportional to its relevance and its validity and indirectly related to how much work it takes to use. So the more work the less useful. If somebody else does the work for you it's infinitely useful. Part of the relevance piece though deals with patient specific outcomes versus the usual things that we measure more easily which are ion fluxes across membranes, lipid levels, things of that nature as opposed to quality of life and survival and those types of things. So we had a chance to meet them and as a result of a conversation in a bar in Houston, which unfortunately is under water right now, um, we developed this whole system of … of alerting physicians. The … we've created this program that has been going on for over twenty years now where we review papers, we synthesize the information, we do critical summaries and … and it's really served as a neat foundation for what practicing physicians can do and try to identify “well can I trust this information or not,” and it's kind of neat to think back that this all started just through a couple of casual homework assignments and, um, and a conversation at a bar at a conference.

MH-R: So is that POEMs you’re talking about?

HB: Yes. The Patient Oriented Evidence that Matters. Yeah, so the “matters” part, is the hard part. So the patient-oriented evidence, you and I understand, quality of life, survival, out-of-pocket expenses, pain. The “matters” part is that, if the information is true and patients are better off as a result you would have to change what you're currently doing.

MH-R: Hm. Mhm.

HB: So it would be a practice change as the … the last piece. That's the harder part I think for people to wrap their heads around.

MH-R: Yeah it is and it's … it's … in some ways that’s similar to what was somewhat radical about clinical decision analysis because that required … that … make … requires that you draw out as you recall, uh, a decision tree that compares strategies, um, like, um, in … you know the famous one is an early stage prostate cancer, where we're comparing doing nothing to radiation, um, or surgery. And then playing out, if you go down each of those paths, um, what are the outcomes. And as you were saying about cost utility analysis you … that's about patient values for those outcomes. And we you know, we talk so much about preference sensitive, uh, problems, where it really makes a difference what you do, how the patient feels about it. So it's not only, um, how good is the evidence? Is it worth making a change about? But then this other piece of really listening to elicit patient values and help patients think through “well if I go down each of these paths, where … where what do I get in terms of side effects what do I get in terms of increased length of life,” or, um, as our favorite cost effectiveness folks like to talk about quality adjusted life years. And that quality adjustment pieces is a big piece. So and I sometimes think that background gets a little bit lost sometimes and that theoretical background is … as we tried to, um, move this along in an … expose the common sense of good evidence to…

HB: And it's not just the common sense of good evidence. It's also about coming back to … at least for clinicians, most clinicians went into medicine, because they want to do well. They want their … they want people to improve their lives. And … and how do we do … well it’s not by the things that we can measure, it's in fact by the things that our patients come in with. They come in pain and we try to alleviate that. They come in because they've got a disease we try to manage and … and improve their quality of life. And it really comes right back to the whole reason why most of us went into medicine in the first place. And … and the best way to do … provide patient centered care is to provide patient centered care.

HB and MH-R: (laugh)

MH-R: And you do it well. (laughs) Yeah and MSU has always, College of Human Medicine has always been, um, a place where new ideas get absorbed into the curriculum pretty easily. Um, and that happened with … with both clinical decision analysis and evidence-based medicine really from early on. You came in ’89?

HB: Yes.

MH-R: Yeah and Arthur Elstein and myself and other people had already started working on a version of focal problems in probably ‘82 or so. Um, under a grant from the National Library of Medicine to really try to incorporate this into, um, our undergraduate medical education. And you did some really good work with, um, getting the evidence-based medicine into the undergraduate curriculum or the residency…?

HB: This was in the undergraduate curriculum…

MH-R: Okay.

HB: So, for many years we really had a … an epidemiology course. And that was about it. Students hated it. The faculty hated the fact that the students hated it.

MH-R: (laughs)

HB: But really didn't have a perspective as to how to improve the course. My department Chair and I, because of our interests in evidence-based medicine we were able to get a grant from … from HRSA, the Human Resources and Services Administration. To create a curriculum track in the third year, that we called Critical Appraisal and Analytic Medicine. Horrible name, but I don't know how that came about. I'm sure there's a story there somewhere. But it was really intended to have two components. The first part where the students would learn how to critically read articles. Then we would turn them loose into the clinical years and have the chance to have questions that arise that they had inadequate answers for. And then they would come back and work in groups, to try to come up with an approach to scholar … in a scholarly manner, how they would actually study this problem. They would actually have to come up with a research methodology, identify validated instruments, and … and actually come up with a plan. We didn't actually require them to do the studies until several years later, when we realized that many of them were doing it anyway. So we … so as a result of this we actually have a situation where our students are now required to do research, even though, please don't tell anybody this, uh, that even though our curriculum committee hasn't signed on to the fact that, uh, that we require it, but it is a required course. Well what we learned though, is that many of the students coming in really needed a different framework and that wasn't coming from the epidemiology course. So we met with the epidemiology department, the course director and helped them to rethink what it is that they want in terms of educational outcomes. Because they were teaching this is if they were trying to train epidemiologists. And it was perfect for that, but that's not what we were trying … that's not what we were asking our students to do. So they ended up restructuring that course. We … they got more curricular time chunked up into some extra time in the first year as well as some time in the second year. In the first year dealt with the foundational issues of “what does it mean to be a clinician in a public health environment,” “issues around data reliability information sources,” those kinds of things. And then in the second year they would actually apply many of those concepts to specific kinds of articles. Which really facilitated that what we did in the third year and actually allowed us to accelerate to really require students to do research projects. So this was really a win-win. Students, um, report of the quality of the teaching and the … it's not perfect but it's far, far better than what it used to be. And it's about where it is on a national average.

MH-R: Yeah. Yeah and I think we talked earlier, you've had some … some students who have found that this puts them head and shoulders above some other students when it comes to looking at their residencies.

HB: Yeah so these … these are research projects they're … they're done in groups. These are students, their … it's their questions. So they originate the question, they have to go through the IRB, they do original data collection, and we've had a number of students come back from the residency interview trail saying “hey, you know what this was embarrassing, because we were in a group interview and they happened to see my CV and … and they asked me about the … about the research project and that dominated the whole interview.”

MH-R: (laughs) Which is a nice problem to have.

HB: Yeah, yeah.

MH-R: Yeah. It's really. And they have it down—they get below the surface through that process.

HB: They understand the messiness. They have to do projects that involve real life people living in the real world. So they have to deal with the messiness of the information sources and the sources of the data and how to … how they might understand them. The limitations of what kind of conclusions they might draw.

MH-R: Yeah.

HB: And planning for future next steps.

MH-R: Right, right. So as we think back we've all … we've both been at this stuff now … (laughs) oh going on thirty years a piece.

HB: Yeah.

MH-R: And now it's become mainstream, a lot of both shared decision-making and evidence-based medicine are taken for granted and they’re still in our curriculum and have been all along. And really have not gotten that much pushback. But the pushback I've gotten from… got in the early years at least was shared decision-making, was really from physicians, because the idea of collaborating with patients around, um, the notion of here is the … here's the information … here is the data and you can go … dramatically different directions and end up making one choice or the other. And they're both legitimate. And to really collaborate that about that. And I remember we, as you know, we have done a lot of work at MSU on developing decision aids, which really are those mostly booklets, certain sometimes DVDs that we provide to patients that give them the evidence to really think about. And I remember you kindly, um, had offered to…

HB: Uh oh, my words are going to come back and haunt me? (laughs)

MH-R: Yeah, yeah. Your words are going to come back and haunt you. Yeah the stable coronary artery disease, um, problem where whether you get—when stable coronary artery disease, like not giving you massive chest pain that's about to give your heart attack but … but about some … angina. And the evidence shows that length of life is the same, whether you get a stent an open that little artery up or whether you leave it alone. And of course this is very disconcerting to … often to patients and a physician. Say what if you've got a blocked artery. Surely if you pop a … a stent in there to prop it open, things will get better.

HB: Or bypass it even.

MH-R: Or bypass it. Right and … and, um, so these different options are ones that have consequences. Obviously for side effects of the interventions of the surgery or even … even the cath and so you kind of … you ended up working with a patient, I remember who had her, um, two specialists telling her she really needed to get to the cath lab, and you…

HB: So we had, we sat down and had a long conversation. Actually a couple of long conversations. And she and I, she just said, “this just doesn't feel quite right. I feel like I'm under pressure and I can't decide between bypass versus stenting,” and well let's … let's have a slightly different conversation and talk about all of the options. And she was quite surprised about that. And when I provided her with a homework assignment to actually go through the DVD and the booklets, she came back and was absolutely astounded on the outcomes. Because nobody had shared that with her. So she had other concerns too because of, um, a co-morbid condition that would have complicated any of those. She came back and said, “you know, I think I just assume stay with medicine. I don't like taking pills but I think the other things are a whole lot worse for me.” So, so she's been on medication management. I just saw her husband a few weeks ago in the office, and I think she's got a visit coming up in a few weeks, but she’s still on medication. She's now about seven or eight years out with no problems whatsoever.

MH-R: Yeah, yeah. And she's one of the brave ones you know, who was willing, with your support, to … to say to her specialists, “no, I even though you know … you know it's a narrowed artery, but I have looked at the evidence and…

HB: When she went back and talked with her cardiologist it was, it was really fascinating because the fellow, the cardiology fellow was the most angry. The senior cardiologist said, “well listen patients have a right to make decisions about what they want and in this case the outcomes are reasonable,” so you know the cardiology fellows you know what they need though. They need experience in order to be … become independent in that and so … so they're looking at things often from a very different perspective but once you get, get away from that you actually try to take care of what the patient needs, that's when the cardiologist’s professionalism really came through.

MH-R: Yeah and it's a big shift from the sort of intuitive, if there is a blockage we must open it up, to saying well but let's look at what we know from the literature about what happens down the line in terms of the increased or decreased risk of dying. Or if it's cancer getting recurrence or, or whatever. Yeah which is now … sort of gradually—I mean, no I say that it's become routine, but it's, as sometimes happens, it's shared decision-making of those sorts of things gets into guidelines more quickly than it gets into everyday practice.

HB: Yeah. I think because of the everyday practice, clinicians are concerned about time and efficiency.

MH-R: Absolutely.

HB: They have a schedule and every fifteen, twenty, thirty, forty, minutes whatever that schedule is they need to make sure that they are staying reasonably on time. And these can be lengthy conversations. The good news is, you can take resources like decision aids, whether it's an online interactive type of program or a simple booklet. And you can give them homework assignments, you can have the conversation sequentially, in most circumstances, you know if you've got somebody that's in the emergency department with crushing chest pain and under … have it… that's not the time for shared decision-making.

MH-R: You’re not going to be making shared decision-making anyway.

HB: Yeah, that's right.

MH-R: Not going to happen.

HB: So… there's a time and a place for this. And most of the time you have a luxury of being able to walk through this and let people stew on it and think about it before they make decisions.

MH-R: Right, right. And in fact even though it feels like “oh” to most clinicians, “this is going to take me forever, I'm not prepared, I don't want to,” the randomized trials of shared decision-making that are in the Cochrane review of decision aids, show an average of about a minute longer in the … to do the shared decision-making with some kind of tool, like you're talking about for the patient to go home and think about it, and talk to their families. So that … that is, that I have to say that's the biggest pushback.

HB: Yeah.

MH-R: I don’t know what you get. Well sometimes I … I suspect, um, clinicians feel that they're being told they're not doing it right or there's something else they have to learn. I don't know what kind of… maybe you don't get that particularly anymore…

HB: And there are some structures on how to know whether you're doing true shared decision-making. There’re checklists and things of that nature but fundamentally for most clinicians, if you've been caring for patients for a while you can be reasonably intuitive. And in terms of the overall approach and it's not abrogating decision making it's actually trying … and it's not about just informing people of the risks and benefits. It's actually trying to understand what is it that is important to the individual, and then supporting them in being able to maximize that … that goal.

MH-R: Mhm, mhm. Yeah I think that's a really true and I think as people get more familiar with these ideas, clinicians and patients, I think it's becoming something of an expectation that they will talk to each other. But of course then the other big pushback is the Internet, and the way the Internet-prepared patient who may show up in your office and really take your time.

HB: Well you know those are actually fun because you know the … the Internet can be a great source of good and evil. And we know that there are sites that are fake sites that are out there and we have to be real careful about that. But most of the … the legitimate sites people find, and they often come in with better questions and better understanding of what's going on. The bigger challenge to me is the one, the patient who comes in with a set of new symptoms and they come in, I call it “pre-diagnosed.” They've self-diagnosed themselves based on what they find in a, on a website. And the challenge there is to say, “you know you might be true, you might be right but let's just step back a little bit and let's look at the full context.” And there are different set of skills in how you address the person who is using this as a set of resources. And then once … once you've moved beyond the diagnosis part and they come in with treatment alternatives, sometimes they come in with very reasonable things that you and I haven't heard about, because they're looking at what's going on at NIH or what's going on at MD Anderson, with regards to some of the personalized medicine approaches. And I think that's … that represents a potential challenge to clinicians especially those who are in the more traditional realm, because the patient now is … has become the expert, right?! They’re certainly, they've always been experts about themselves but in some ways they're also, because they have a vested interest in their care, they're now an expert about that as well. And I think that's actually an okay thing.

MH-R: Yeah. I think that's really great. And I have to say, I do think, as I interact with our students that because they're part of contemporary culture, to them the answers are all on the Internet. Of course that's another, that's a, that’s a story for an … a difficulty for another day. But I do think over the time we've been working on this, that the ideas of a clinician-patient negotiation are no longer strange and the note, and the idea that there is a lot of good evidence out there for you to get if you're a patient is just starting to be, um, established.

HB: Yeah. I … I do think there's a bit of a caution though. And that is, that, um, we have to be careful about who is asking the research questions these days.

MH-R: Yes.

HB: And how is research funded and you know, we've talked in our … in various other settings about publication bias for example, where, um, studies that might not be favorable to an intervention may not see the light of day.

MH-R: Right.

HB: A great example of that is the data on, um, Oseltamivir in the management of patients with influenza. About half of the data have never been published and when you take the data that haven't been published, the studies themselves are high quality, would pass muster going through the peer review process, and when you incorporate all of those data with all of the published data, it turns out that the overall effectiveness ain't so great. And yet patients will come in, asking for Oseltamivir or other comparable agents. The CDC has certainly stockpiled all of this stuff. Um, and it's, and it’s largely because of selective publication. And … and so we have a real challenge when profit is the motive around the kinds of questions that are asked and the data that are released. Patients may not have the sophistication to understand that aspect. And so there is this … this challenge that …that clinicians need to be aware. By the way most clinicians don't think about that either. They just assume that because it was in Lancet or the New England Journal it must be true.

MH-R: Right.

HB: So we have to go back then to our original story. (laughs)

MH-R: We do, we do. And teaching skepticism to both medical students and patients may be the central thing that we have to keep doing through these … these cases and writing these tools.

HB: Yeah and the other part is who they study. Most of the time, I care for individuals. So like my patient with new onset coronary artery disease, new onset angina with other co-morbid conditions. I have patients with diabetes, hypertension, chronic obstructive pulmonary disease, severe arthritis, asthma, you name, I mean a whole series of things. And if I just focused on the one thing in the study, I might be able to treat that really, really effectively but, oh by the way probably worsen at least one of their other co-morbid conditions and maybe adversely affect their quality of life as well. And so, so this is one of those application challenges that clinicians really struggle with.

MH-R: True.

HB: Because not only are they trying to do what the study says, the guidelines often are constructed around patients without co-morbid conditions. And all of the incentive plans around pay for performance the quality improvement activities also focus on the person with single co-morbid conditions. Whereas you know, when we engage a conversation with the patient and focus on whatever aspect of quality of life and survival that are important to them, we might make very different choices.

MH-R: That's true. And … but the guide … but frequently these guidelines are doing things like including patients on… in the guidance overall of what goes on in the organization. Both for research and for practice. So, the general … the whole general framework has … or the … the public has moved on to incorporate these things but still the fundamental challenges are still there.

HB: So there's still a lot of perverse incentives even though we're starting to see some general… I think it will take some time for that … for people to realize that oh maybe there is benefit to be had by focusing on functional status, and quality of life, and as opposed to micro measures of disease management.

MH-R: Oh I think we continue to, I think our challenge is what will keep us busy for as long as we are interested in doing this work. And passing it on to our junior colleagues.

HB: Yeah. And fundamentally I think, you know, if … for clinicians who really care about their patients. This is, this is you know independent of all of the other things, this takes you right back to foundational things. You can use all of these tools to try to enhance the decision making that … that takes place in the course of an office visit, or a series of office visits to help our patients maximize their own personal health goals.

MH-R: Yeah you know. So there's the agenda for the future.

HB: Yeah.

LM: Thank you for joining us today. Please visit us online at, and follow us on Twitter at @MSUbioethics. This episode of No Easy Answers in Bioethics was produced and edited by Liz McDaniel.