Helping Patients Make the Best Medical Decisions

Dale Collins, MD: TDI's New Director of the Center for Informed Choice

June 15, 2009

	Dale Collins, MD

"I want to feel confident my patients are making good decisions," says Dale Collins, MD, the newly named Director of the Center for Informed Choice at The Dartmouth Institute for Health Policy and Clinical Practice (TDI). A plastic surgeon who specializes in breast reconstruction, Collins will bring a clinical perspective to the development and implementation of shared decision making for patients facing tough medical issues. "Patients receive better care when they take an active role in decisions about their health. They need to be informed to make good decisions, and good decisions vary from patient to patient. Because patients have different values, there is no right or wrong choice of treatment, but a best choice that is unique to each person," Collins says.

A researcher as well as a surgeon, Collins came to Dartmouth in 1995 to study Outcomes Research with John "Jack" Wennberg, MD, founder of The Center for the Evaluative Clinical Sciences, now known as TDI. Collins earned her Masters of Science while practicing at Dartmouth-Hitchcock Medical Center. In 1999, she joined the Norris Cotton Cancer Center, as the Medical Director of the Comprehensive Breast Program, an interdisciplinary clinic that integrates patient education materials with decision-making aids for women diagnosed with breast cancer. "It's difficult for patients to absorb and integrate information, especially when they have just received a serious diagnosis. Patients need good information to make good decisions, and they need time to absorb it." In her recent research, Collins has proven that giving patients decision-making tools that take into account a patient's values as well as possible outcomes helps patients make the best choices on a case-by-case basis.

"A clear example of patient preference would be a woman choosing a mastectomy instead of a lumpectomy," Collins explains. "Clinically, they're the same, but emotionally, they're not. Some women chose breast reconstruction, others don't. These are important decisions that only the patient can make."

One of six centers of excellence at TDI, the Center for Informed Choice (CIC) is dedicated to making patients partners in care through shared decision making and informed choice, which is decidedly not the same as informed consent. The three main goals of the CIC are: 1) to create pioneering educational programs about the theories, measurement methods, and research designs involved in studying shared decision making; 2) to investigate fundamental and applied research questions in key aspects of the shared-decision making process; and 3) to design and test innovative clinical practice models that incorporate shared decision making as an integral part of care. 

"Dartmouth is the only academic center in the world with a hospital-based clinical and research center for shared decision making," Collins says. As director, she plans to promote research, to educate medical students and clinicians, and to promote the results of CIC's research to improve patient care and healthcare policy. 

Collins will be aided by co-director Hilary Llewellyn-Thomas, PhD, Professor in the Department of Community and Family Medicine, who specializes in designing research projects and teaching research techniques to investigators. "While some of this research takes place in the laboratory and classroom," Llewellyn-Thomas explains, "most of it takes place in the clinical setting. It's great to have a clinical leader like Dale to lead CIC. She really understands the importance of fostering individual-based, patient-sensitive, and rational approaches to decision making. Changing systems and getting new information and tools to patients require clinical champions like Dale, who are willing to rethink and redesign clinical work flow patterns to accommodate new ideas in education, research, and practice." 

Collins' work with the Comprehensive Breast Cancer Program at the Cancer Center has made her a national leader in implementing a shared decision-making process into comprehensive, coordinated patient care. At CIC, Collins plans to build on that work. "We need to do research around what are the right questions to ask: what's important for the patient to understand? How do we help people integrate their personal values into their decision making? Our goal is to help patients make choices consistent with their values—what's uniquely right for them." In her work as a surgeon, Collins has used Patients' Decision Aids—tools designed to help patients understand their disease and their own preference for treatment based on their thorough understanding of their core values along with the likely outcomes of the different options available. 

Several departments at DHMC already have shared decision making processes in place for a variety of choices patients face, ranging from deciding to undergo cancer-screening procedures to decisions about palliative care. A link from the Spine Center's web-page, for instance, leads to informational videos and DVDs available on loan, web-based decision aids, and a healthcare decision guide for patients with low back pain. Properly informed patients and their physicians can then decide on the best course of treatment for a particular problem at a particular time. 

In addition to research, CIC's mission includes translating results into the clinical setting, and influencing policy that will ultimately reward those clinicians who provide good information that helps patients make the medical choices best for them. Collins looks forward to the day when a medical center's use of a shared decision-making process becomes one of the measures of an institution's quality of care.