Use your B.R.A.I.N. A Decision Support Tool

The Centre for Collaboration, Motivation, and Innovation (CCMI) is a non-profit organization dedicated to building skills and confidence for better health and health care. Their vision is "to improve health outcomes through helping people take active roles in their health."

The BRAIN Informed Decision Making Aid

Achieving this vision entails the development of tools that can facilitate patient-provider conversations. To that end, they have adapted the BRAIN Informed Decision Making tool from the International Childbirth Association.

At the recent BC Patient Safety Quality Council's Quality Forum (#QF16), I was asked to give a talk on Choosing Wisely and was put into the "Patient Empowerment" breakout session. It was fortuitous that my talk preceded that of the CCMI team as I got to see their presentation on the tool and learn about its development (slides accessible here).

Helping a patient to explore the [B]enefits, [R]isks, [A]lternatives, their [I]ntuition, and [N]ext steps, the BRAIN tool can assist people navigating any significant health choice.

You can view and download the PDF on the CCMI's website. The simple format and generalizability means it could easily become a 'go to' tool for patients and clinicians who wish to engage in shared decision-making.

Please feel free to leave your feedback on this tool in the comments section below; the input can be forwarded to the CCMI team. Has it been a helpful tool for you as a patient or caregiver? Do your patients find the format straightforward?


Seeking more tools like this to facilitate patient-provider discussions around important health choices? Less is More includes a list of mainly Shared Decision Making Tools, in the hands-on resource section.


Disutility: Finding the balance between benefit and hassle

James McCormack (@medmyths, The Best Science Medicine Podcast) sent me a great article: "Patient-Accessible Tool for Shared Decision Making in Cardiovascular Primary Prevention."

The UK group looked at the problem of patients discontinuing medication and focussed in particular on statins for primary prevention of cardiovascular events. A lot of research assumes that the 'burden' of taking a pill is a negligible factor in medication adherence, but these researchers thought otherwise. They surveyed 360 people to see how they might balance their potential cardiac risk with the 'disutility' of a preventative, once a day medication as intervention. Paraphrasing, they wanted to know:

how much longer would a person need to live (thanks to a medication) in order to make it worth the hassle of taking the medication

The article is worth sharing because it introduced a few new ideas to me:

  • "disutility" : a word the researchers use to capture the idea of inconvenience or burden of care
  • there is some good evidence that educating people more and more about their risk will not change their adherence to medication
  • talking about reasons they would not want to take the medication may be more important
  • as every person has a different tolerance of disutility, individualized discussions (shared decision-making) still remains a good strategy
  • for people who fall in the middle ground when balancing utility and disutility, factors like gender, smoking, blood pressure, and cholesterol factor into the decision whereas they do not for those with high or low disutility

Figure 4.

Disutility vs utility. Frequency distribution of disutility, longevity benefit that subjects expressed a desire to make tablet therapy worthwhile (top), and the frequency distribution of utility, actual expected gain in lifespan from statin therapy in the English population (bottom). The difference between the 2 values is the net benefit of tablet therapy. Because utility has a very much narrower spectrum than disutility, for those with a high disutility, regardless of utility, statins are a net harm; for those with low disutility, regardless of utility statins are a net benefit. It is only for those in the middle gray zone (top) that sex, smoking status, blood pressure, and cholesterol are the deciding factors.

Read the full article here, in Circulation. 

If you are very interested in the idea of 'disutility,' you may enjoy Dr Victor Montori (@vmontori)'s work on "Minimally Disruptive Medicine."

CONFERENCE: ISDM/ISEHC2015: Bringing Evidence-Based Practice and Shared Decision-Making Together

What could be better than a conference combining evidence-based practice (EBM) and shared decision making (SDM)!? 

A conference combining EBM and SDM... in Australia!!

That's right, July 19-22, the University of Sydney will be hosting the joint international shared decision-making (ISDM) and International Society for Evidence Based Health Care (ISEHC) conference.

Drs Paul Glasziou (@PaulGlasziou) and Lyndal Trevena (@LyndalTrevena) host, with keynote speeches from Drs Victor Montori (@VMontori), Alexandra Barratt (U of Sydney, organizing committee of Preventing Overdiagnosis), and Sharon Strauss (U of Toronto).

Submit an abstract today! Early bird registration will open soon, and close April 17, 2015. Check out the website and subscribe to their email list so you know as soon as registration opens.


Find out about other conferences and events on the subject of Overdiagnosis, the application of evidence and shared decision-making, and Less is More in Medicine.

Social Determinants of Health (#SDOH); the bigger solution

When thinking about the health of a population, it seems that many acknowledge the role of public health and preventative medicine. We talk often about the context of the patient, their "Social Determinants of Health."

On a 1:1 clinical encounter, I often feel like I'm hardly doing anything useful. I'm just treating some numbers, doing something to the patient, not really doing anything for the patient.

It Seems I'm  'spit-polishing' the giant dent in the car, when I help an obese, diabetic patient adjust their dose of insulin.

You  could  take it in for repairs... but maybe better to have prevented this? (Image from  Bob Ottenhoff )

You could take it in for repairs... but maybe better to have prevented this? (Image from Bob Ottenhoff)

It's not clear how much of a difference this test-ordering, medication optimizing, target-setting, or patient educating makes. It feels like we are "helping" but at the same time, it feels often that we are just occupying time and resources when we could be investing these in a more effective way.

Dr. Leana Wen, writing Help patients by addressing the health of the community for KevinMD, puts it well:

We need comprehensive strategies that promote health and target problems “upstream.” We need to recognize that health does not exist in a vacuum, that it is intimately tied to issues such as literacy, employment, transportation, crime, and poverty. An MRI here, a prescription there — these are Band-Aids, not lasting solutions. Our communities need innovative approaches to pressing issues like homelessness, drug addiction, obesity, and lack of mental health services.

The Canadian Centre for Policy Alternatives "gets it." Their paper, Sustainable health care begins with the social determinants of health: It’s time to get it right concisely summarizes the data and emphasizes that solutions that decrease spending on the medical aspects of health (eg. private healthcare) will only worsen economic disparity, worsening health.

How do we convince governments, who must work within the bounds of election cycles, that a long-term plan that addresses patients bigger needs is the wisest choice?


Choosing Wisely Canda: Launch Today!

I can't tell you how excited I am that Choosing Wisely Canada is now live!

Their resources will make discussions between Canadian patients and healthcare providers far more appropriate. The ideas showcased here provide a place for starting a dialogue, inspire patients to ask "why" questions about care, and encourage physicians to think twice about testing and treatment options.

Explore Choosing Wisely Canada.

The first wave includes Top 5 "don't" lists for specialities such as cardiology, family practice, orthopedics, and more. These are evidence-informed guides suggesting avoidance of certain tests and treatments in specific contexts.

The message is not "never" but rather "think twice about," and beware that every test and treatment may bear risks and harms that make it the wrong choice for some patients.

Many of us welcome all the tools we can get for the Shared Decision Making (SDM) approach. This is just Wave 1, and lots more evidence-informed speciality lists will be released soon.

By way of disclosure, I'm a member of the Canadian Medical Association (CMA) and have been involved for just over a year with their work on Health Care Transformation. I was not directly a part of the development of Choosing Wisely. The CMA's role in this timely and important effort is a significant achievement in advocacy and health policy, and I couldn't be prouder to stand with them.