The ElderDerm: Episode 3, Shared-Decision Making

In our next segment of the ElderDerm Podcast, listen to co-hosts Dr Adam Friedman and Jaya Manjunath discuss what shared decision-making is, why it is important in dermatology, as well as common challenging scenarios where shared decision-making is particularly important to consider in the older adult dermatology population. Stay tuned, more to come soon!

Adam Friedman, MD, FAAD, is the Chair of Dermatology at GW School of Medicine and Health Sciences.

Jaya Manjunath, is a third-year medical student at GW and the founder of the 501(c)(3) nonprofit organization, Seniors with Skills, an international nonprofit with a mission to end social isolation amongst senior citizens.

ElderDerm 2024 is the first conference uniquely dedicated to highlighting the complexities in medical treatment and social considerations in older adult patients. The conference will be held on June 6, 2024, at George Washington University in DC. In addition to addressing these important topics, the conference will foster collaborations between clinical researchers and practitioners and will fuel the development of future research studies and clinical trials in the field of geriatric dermatology. We hope you choose to attend and support this conference! 

Transcript:
 

Dr Friedman: All right, everybody, welcome back to the ElderDerm podcast. I'm one of your cohost, Dr Adam Friedman, professor and chair of dermatology at GW School of Medicine and Health Sciences, and I'm joined by Geri Derm, Jazzagirl Jaya, who is actually a medical student here, as well, and she's joining me today to discuss shared decision making with a little twist in terms of considering this important tool as it applies to our geriatric patient population.

Jaya, it is good to see you.

Jaya Manjunath: Thank you for having me on for another podcast, Dr Friedman. So glad to be here.

Dr Friedman: But of course. well, let's just get right into it.

You know, I feel like we hear this term shared decision making a lot. It's a lot of industry sponsor decks. We see all these kinds of like circle based figures with little different pieces of the pie of what goes into it.

But even though we hear about all time, maybe it'd be good to actually would love your perspective as a medical student. What does that even mean? mean? And with respect to geriatric dermatology patients, why is it important?

Jaya Manjunath: Yeah, so I mean, basically in medicine, a shared decision -making is the overall collaborative approach to care, which aims to sort of jointly determine management plans of conditions, including patient preferences. And it really stems from the understanding that patients should have a significant role in shaping their health care and should have their individual values, preferences and circumstances known to their provider. And shared decision making is really important in the older adult population, given that many of them have unfortunately impaired cognitive status in my personal interactions. They've had ability inability to tolerate procedures, life expectancy, can be an important consideration as population, as well as ability of family to support them in their healthcare.

So, these are important considerations to be made. And really shared decision making is all about asking the patient, what do you want? Because in traditional medicine forums, hundreds and hundreds of years ago, I mean, it was really just doctors telling the patients, you know, this is the treatment plan, this is what you're going to do. But really, this shared decision making, -making is all about empowering the patient, and they're more likely to follow through with their treatment plan if they are ultimately involved in their own care.

Dr Friedman: So clinical collaboration is what I'm hearing, and they're going to be part of that clinical team. And now, clearly, I'm going to have to ask because, you know, it's one thing to define, but it's another to get a translatable example. Can you share a case where shared decision making impacted the outcome, the treatment plan in an older adult patient that you would interface with?

Jaya Manjunath: Sounds good. Yeah, I can definitely provide an example. So, a few months ago, I conducted a skin check on a woman in our clinic who was about 90 years old or so.

During the exam, we performed a biopsy on a lesion that had features of a basal cell carcinoma and then the pathology came back as a superficial basal cell and when we talked to her we were really considering how these sort of low these sort of basal cells have a low risk of growth or they're slow growing in nature and we kind of assessed whether or not the potential risks of treatment outweighed the benefits. So, one management strategy that we can was active surveillance in this case.

And it seemed appropriate because the patient wasn't immunocompromised. There was sort of this histologically lower concerning feature of a superficial type of basal cell. The lesion was smaller than one centimeter.

It was asymptomatic, her primary lesion, etc. So, we kind of had this extensive conversation involving the patient, her daughter was there, and the dermatologist was there as well.

And the patient sort of led to the decision to opt for watchful waiting, and this approach was essentially chosen based on a comprehensive assessment of what the patient wanted, as well as the risks and benefits. And I think that ultimately the takeaway from this example I'm sharing is, there may be reasons why you don't excise immediately.

Like limited life expectancy, severe cognitive impairment. all these sorts of considerations should be made in each individual patient case. And that's just sort of an example where we use shared decision -making.

Dr Friedman: Yeah, you know, I love that you brought this example, and I know we're going to get into the meat of this at our conference in June, the first ever ElderDerm Conference here at UW. But as you were discussing it, I was reminded not so much of one of my cases and my practice, which I have this very conversation pretty regularly in terms of opting to do watchful waiting, field therapy when typically, it wouldn't be appropriate on certain areas because of recurrent rates, but given the patient's age and other factors we go that route.

But the very first time where this became very clear to me was actually related to a family member, I guess you called my grandfather -in -law, 93-year-old guy who had a squamous on his scalp and the physician who made the diagnosis wanted him to do most surgery. I was kind of freshly out of residency as junior faculty member.

And of course, the family asked what my opinion was. And it was incredible to me that like you really think this is going to hurt this guy? Like he's 93 years old, you know, it was a small lesion not ulcerated not bleeding not causing any impairment and you're going to have him undergo you know surgery on the scalp which is going to be very rigid and very difficult for healing and that was one of those aha moments I’m like just let it go like if it becomes a problem just let it let it ride. I mean this is not going to do him in and I think that was an example where there wasn't shared decision making where he was told this is what you have to do. And I had to intervene.

So, I think those are 2 good examples of opposite end of the spectrum of considering the patient where they're at and what they're able to do. And here we're talking about skin cancer. But even when you think about something as simple as applying a topical twice a day to an area that can't be reached, you know, I think that it's not about apply this twice a day and call me in the morning. It's hey, there are a couple of ways to approach this. I can give you something you can put on this twice a day. Do you think you'll be able to do that? Do you think you can actually reach that? I think that that is another kind of way of thinking about shared decision making is the patient's ability adds to that decision.

And maybe that comes into some of the challenges for incorporating shared decision making, which, you know, let's be real, derm is fast -paced, high -volume, volume, you know, academics. I feel like I have it easy having patients every 15 minutes when others do every 10 or 8 minutes.

So how do you get that in and make it meaningful without undercutting the workflow and in clinic?

Jaya Manjunath: Yeah, I mean, exactly what you're saying. It's really, really tough, especially when a patient has, you know, brought their whole family along with them and they want it to be meaningful to have that really lengthy conversation.

And like you were saying, the clinic visit might only be 8 to 10 minutes. I mean, how do you get that all in? And it really just comes down to prioritizing. And, you know, maybe a patient comes with a list of 10 different to -do items or 10 different problems.

And maybe this visit we address only, we address the first 3 or the most pressing 3, and then they come back for that next follow -up and that's kind of how, at least I've seen a successful approach when a patient comes in with 10 or 12 different problems. But in terms of the other challenges for shared decision -making, what I've seen is in cases with cognitive decline, which I was kind of talking about earlier, where guardianship has not been established, which it can be really tough to ensure that patients understand their treatment plans. And I have personally also seen disagreements between patient and family caregivers that can result from these shared decision -making conversations. And even if a patient wants to undergo a certain treatment plan, they may not have this proper support at home to manage their medications.

They may not be able to reach that area, like you were saying for a topical medication. They may not be able to come back with additional transportation to come for a follow -up excision. So, you know, these are all different challenges and, you know, we've also been talking about end -of -life care.

Having those palliative care discussions can be really challenging and time  consuming and I'm not sure how to fit that into like an eight to 10 minute conversation. And also managing patients with multiple comorbidities who are coming in with that very, very low list of medications and figuring out if we're adding, say, a systemic medication, do we need to consider interactions with another medication on the list? Should we consider removing another medication? These can all be challenges. But I will say with shared decision making, one key point I want to highlight is that a lot of times dermatologists may lack access to decision aids regarding these topics.

So, for example, for watch the waiting of basal cell, I have seen some recommendations published online, but I haven't seen firm set guidelines where, you know, if this then this. So, I feel like sometimes dermatologists may find themselves in sort of this guideline deficient scenario where they're kind of trying to figure out what to do in the best approach for the patient.

Dr Friedman: Yeah, I think that that's a great point, and I would argue, that there are a lot of areas in dermatology where we don't have set guidelines and it does take a long time and a lot of energy and I will say funding to get these kind of consensus statements doesn't mean they shouldn't be pursued. I think that's a great point is could you get a group of people together to decide what resources are most helpful, but also to maybe identify those gaps where new resources can be useful.

But to that end, handouts, handouts, handouts, handouts. I think handouts are extremely important. One trick I will suggest is that you can find this online, making sure the language of your handout is in understandable language. Really a handout should not be in language that is more complicated than a 6th to maybe 7th grade reading level. You know, I remember hearing my, you know, my own family is saying like, when you're a doctor, make sure to not talk in doctor talk.

And, you know, we see this on TV where, you know, a very classic example of a physician, very stoic and, you know, serious is relaying lab results to a patient, like, I don't know what you're talking about. You know, we would never do that. But when you're rushed, you fall back on the language in which  you're fluent. And so even just having things in easily digestible language or in thinking about the geriatric population, maybe a larger font, for example, things like that is really, really important. The other thing I want to kind of hit on is something you mentioned about transportation.

It is not easy for many of these patients to get in, and that's where purposeful education on telemedicine could actually be quite helpful. You know, telemedicine is alive and well, especially teledermatology. Certainly, there's some shortcomings when it comes to this population in terms of technology literacy or access to technology, but that's where some education around this could potentially be helpful so that you're only bringing them into the office when it's absolutely necessary.

And so, if you want to consider putting a patient on a medication that requires close follow -up, sometimes those follow -up visits could literally be a matter of minutes, but you just dragged them in, and they had a assessor ride come and get them and they had to leave 2 hours early. Like, there are all these things to think about that really adds to their day versus the visit itself.

You know, think about that. So, we mentioned a couple. We mentioned application medications, polypharmacy, you know, how will giving this medication affect their other meds waiting for skin cancers.

Are there any other common challenging scenarios in which shared decision making could really make the difference and really should be considered for this patient population?

Jaya Manjunath: Yeah, definitely, I can just talk about one for now. So, I, as you know, I spent a lot of time in the itch clinic.

So, itch treatment escalation is definitely one common challenging scenario I've seen. when it comes to treating older adults. And my personal research focus this year has been on chronic pruritus of unknown origin, which is basically itch without a rash for greater than 6 years.

It's prevalent amongst the older adult population. And basically, where we see that challenge often is in itch patients where they're uncontrolled after topical steroid use to basically the decision of escalating to systemic therapies, for example, methotrexate or dupilumab, and this can be challenging because overall, for older adults, there's very limited safety data available, and there's very limited inclusion of older adults in randomized trials for systemic therapies. So really kind of make the decision -making process for starting a systemic takes into account potential risks and benefits. So, for example, methotrexate can affect liver enzymes and cause GI distress, but has the longest history of use.

Gabapentin can cause somnolence. Dupilumab is a newer therapy, and it is relatively well tolerated, especially in other conditions with a limited side effect profile. But oftentimes we've seen insurance coverage issues that arise in this patient population as well.

So, yeah, this is definitely the case, one example that I commonly see that can be challenging, escalating its treatment. Another common scenario I see is honestly in the treatment of actinic keratosis or AK.

I often see decision -making regarding whether or not the patient should be started on fluorouracil, which is a medication that can have a lot of adverse effects, like erythema, scaling down. scaling, crusting, etc. Starting that versus just the liquid nitrogen, the freezing versus watchful waiting, which is kind of what we're talking about before.

So that's another common challenging example I've seen for shared decision -making has been important in care.

Dr Friedman: Yeah, no, those are all great examples. And I'm glad we're talking about access.

One you mentioned is coverage. And it drives me nuts when Medicare will cover a medication, but the copay is a kidney. And it's, you know, there's no PA to do it's like, oh, it's covered, but your copay is out of control.

And so, you know, what one helpful thing and that goes to share decision making is when that happens, I'll discuss with patients, you know, listen for a drug that might be joshed every 2 weeks. I can't give samples forever for something that that frequent, but maybe what if I gave you 1 dose that will offset the, you know, half the cost. So, like you'll have to lay out would buying half the years’ worth be reasonable based on your means.

And I can try to work out getting the rest. Obviously a lot of patients can't do that, but that's where once again, that conversation is how do we get patients medications in the climate that really is not for access to medications? And I think samples are hugely important. To your point also about our very limited understanding of how these drugs work in elderly populations that are often not included in these trials. Well, the only way you know is if you get to try it.

And I think having access to samples really enables that, especially at the resident young physician level. So those I think are very important.

And I think that discussion about, hey, I can give you a certain amount? Let's try it out—that goes into that shared decision -making. But I think what I'm really getting from our discussion is there's a great opportunity, not just to employ shared decision -making, but there's a great opportunity to set better standards of how to use it and how to use it efficiently, and so I'm just going to put that on your shoulders.

You can figure this out. You're young and smart. I'm sure you have some spare time to, to fix this problem. Knowledge, I think there's a lot of opportunity to make a difference. And I think from the get-go is just having that mindset of asking basic questions that can really guide how you really cajole and create your, your treatment plans, but also, just to throw this out there because I know everyone's like, "I don't have time for this, possibly”, it's that it actually makes, it'll save you time. Because if you don't have these conversations, you create a treatment plan, you just write certain medications.

If the patient can't get the medication, they can't apply the medication, you're going to get a phone call. The patient's going to come back, no difference, they couldn't do anything. Maybe you'll get a negative Yelp review from their favorite nephew.

All those things are certainly possible. So, I think, you know, it is in your best interest to really employ this, this approach. Jaya is always a pleasure speaking with you. I'll give you the floor for the final thoughts and any final thoughts to share with the audience.

Jaya Manjunath: I think that overall, I have just been really happy to see the growth of shared decision making over time. I remember honestly shadowing as a high school student and to be honest, at that time I was seeing a lot of positions just doing what we were talking about before. Just telling the patient, this is what it is, this is what you're doing, and that's it. And I've just seen, as I've grown throughout undergrad and medical school, a lot more physicians employing shared decision -making. And I'm hoping that it's a trend that will continue and it really, really does positively impact patient care. And I hope that everyone from this podcast can really take that away.

Dr Friedman: Great, well, thank you so much for your time and insights. And everyone stay tuned to the next edition of the ElderDerm podcast, have a great day.