Written by Kymberlie McNicholas, Founder of The Way to My Heart

“The focus of {shared decision-making} is in clarifying the patient’s values and quantifying them right away so any doctor could look at them and apply the circumstances at-hand to create a personalized treatment plan,” explains University of Michigan Medicine’s Dr. Matthew Corriere.

As part of our ongoing Vascular Innovation Series in conjunction with The Way to My Heart, Emmy Award-winning Journalist Kym McNicholas interviews Dr. Matthew Corriere, a Vascular Surgeon and Frankel professor of Cardiovascular Surgery with the University of Michigan about the critical need for shared decision-making in the treatment of Peripheral Artery Disease. 

Dr. Corriere, talk about the critical need for shared decision-making in the treatment of Peripheral Artery Disease. 

There’s often a real mismatch between goals and treatment experiences among patients. I find it leads to two extremes:  some patients are getting undertreated and some are getting overtreated. Those are two areas in which shared decision-making might help impact treatment choices, leading to better patient outcomes.  

When we see patients in clinic, it’s very fast-paced and there are a lot of time constraints on the doctor. So, it’s really important that we have a set of tools that help patients identify what’s important to them and get comfortable putting that in front of the doctor and trying to engage them… to get on the same page in terms of what the goals are and what a successful outcome looks like. What success looks like may be different for each patient, and their individual goals should influence how we approach their treatment and judge their results.  

Who’s involved with the shared decision-making? It’s relevant to all treatment decisions, regardless of whether it’s medical therapy or a revascularization procedure under consideration. It potentially involves the Primary Care Physician, the Vascular Surgeon or Interventional Radiologist or Cardiologist as well as the patient. The focus of it is in clarifying the patient’s values and quantifying them right away so any doctor could understand the information and apply it to the circumstances at hand to create a personalized treatment plan.  

PAD is so complicated because you can do medical therapy, you can do exercise therapy, you can do angioplasty procedures, and/or you can do bypasses. You can even invoke several of those at one time. With shared decision-making, rather than trying to collect information from the patient and spit out, “Here’s the treatment you need,” it’s more about saying, “Here’s what’s important to you based on your responses and the kind of questions to ask when you see your doctor, whether it’s your primary care physician or, or a specialist like me.” Once this discussion occurs and a patient gets a list of recommendations, I don’t think it’s ever a bad idea to get a second opinion if you are concerned that you and your doctor don’t share mutual goals and understanding.

When I started researching whether shared decision-making could make a difference in patient outcomes, one of my collaborators said, “You know, my mother is 75 and you’re an expert and she’s coming to you for your recommendations.  She is not interested in trying to help you decide. That’s your job.” A survey study we did, however, suggests otherwise.  Over 90% of our clinic patients actually indicated that they wanted to hear about all the options under consideration, rather than the doctor just tell them the option they favor most.   The majority of patients  (70 percent) additionally indicated that they would not find that additional information overwhelming, which was one of our concerns. So, we have to break through the paternalistic notion that the doctor chooses for, rather than with, the patient. 

The general idea behind shared decision-making is that we need to treat patients more like partners in their care instead of just being a recipient of the doctor’s recommendation.  We need to see that patient as a person, and not a lesion blocking an artery.  We need to factor in the social contexts and expectations in their life to prevent missing an opportunity to establish mutual goals before deciding upon a treatment path. This process strengthens the trust between doctors and patients. Even if I am skilled at revascularization procedures, the patient should know that there are other options available, including medical treatment or observation which may be acceptable to them.   For example, some patients want the option that will give them the most improvement or the most durable results and will accept the risks that go with a revascularization procedure.  Others may want to avoid a procedure if at all possible, even if their symptoms will persist.  We should tailor both our counseling and our plan based on that information. 

There are specific standard protocols for the treatment of PAD, whether it’s by insurance, government policy, facility standard protocols, along with physician strengths and treatment preference. How does that factor into shared decision-making?

PAD is seldom the patient’s only medical problem, and therefore should not be treated as if it exists in a vacuum. Every patient is different, and their entire picture must be considered if we want to improve PAD outcomes. For example, if the physician focuses only on the PAD diagnosis and ignores that the patient also has severe lung disease or arthritis, we may overestimate the potential for the PAD treatment to benefit the patient in terms of walking or daily activities. This consideration isn’t just related to revascularization procedures but also applies to supervised exercise therapy.  Although supervised exercise therapy is important and frontline treatment for PAD, not all patients are willing and able to l do it (especially if their other medical problems make it challenging to participate). Sometimes there is also a power dynamic where patients may feel uncomfortable telling their doctor they can’t or won’t be able to do walking exercise therapy because they don’t want to disagree with the recommendation.  These circumstances are common and may lead to several months being lost while trying a therapy that may have been unrealistic, or with the patient taking their PAD care elsewhere rather than raising an objection directly. Neither the patient nor their doctor wants the visit to be a waste of time, so we must do a better job of matching the patient’s goals and capabilities with what is reasonable to offer from a medical perspective. It doesn’t mean to do a procedure on someone when we know it’s medically inappropriate simply because the patient wants it. Instead, It means empowering the patient through a candid discussion that offers clear options and treats them as a partner in the choice. 

We are working with the FDA on a research project related to patient-reported outcomes. Beyond shared decisions, patient-reported outcomes go even further asking the patient to help judge whether the treatment was successful. This is important because there is sometimes a gap between how medical researchers and patients view outcomes.  For example, if the patient’s goal was to walk enough to be able to cut their own grass and the treatment did not achieve that, they might judge their outcome to be unsuccessful.  That might be inconsistent with the medical research interpretation, which often instead focuses on changes in leg pressures or walking distance that may not translate into a better quality of life for the patient.

In your research, what’s preventing these productive and satisfying conversations from occurring? 

A recent study we did at the University of Michigan analyzed recorded conversations between doctors and patients during clinic visits for PAD.  We looked at how much the different parties spoke and how much were they interrupted. We were pleased to observe a pretty even split between how much the doctors versus the patients talked during the visits. We were impressed, however, by how often patients were interrupted while speaking: an average of 38 times per visit.  Interruptions came from family members almost as often as medical personnel.  These observations make us wonder what be gained by letting the patient finish what they are saying instead of interrupting them. We also found that only 18% of the conversation was related to shared decision-making, and of that most was simply the doctor describing the options available to the patient. Very little time was spent asking the patients about their preferences.  The takeaways here are that we could definitely improve in terms of listening to patients and eliciting their preferences.  We need to enable patients to speak up about what benefits they hope to achieve, what harms they hope to avoid, and how we can develop an individualized treatment plan based on that information.

To hear more about Dr. Corriere’s research, including specific results, watch the video interview


This interview was produced by The Way To My Heart in partnership with Vascular Cures. Neither The Way To My Heart nor Vascular Cures endorse any specific products, entrepreneurs, companies, organizations, drug or device trials, and/or healthcare professionals, including diagnosis or treatment programs. The information, advice, and views shared in this interview are that of the individual speakers and are offered for educational and informational purposes only.

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