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September 25, 2017

How Memorial Sloan Kettering curbed overtreatment—with an assist from Harvard Business School

Daily Briefing

    To improve patient-provider communication, doctors at Memorial Sloan Kettering Cancer Center have integrated Harvard Business School negotiation tactics into conversations with prostate cancer patients, Lucette Lagnado writes for the Wall Street Journal.

    Here are the most important factors for success—it starts with clinician-patient communication

    A 'very frustrating' situation

    According to Lagnado, research indicates that men with low-grade, early-stage prostate cancer can safely opt for active surveillance over radical procedures such as radiation or surgery. However, despite medical consensus that active surveillance is usually the appropriate treatment for small, early tumors, roughly 50 percent of eligible men undergo radiation or surgery. And while those procedures can be effective for early-stage prostate cancer, experts caution that they can have potentially serious side effects, such as sexual dysfunction, urinary incontinence, or bowel issues.

    Behfar Ehdaie, a physician at Sloan Kettering, experienced this firsthand among his prostate cancer patients. In Ehdaie's opinion, too many of them opted for radiation or surgery despite his recommendation of active surveillance. "It was very frustrating," he said. "They didn't see active surveillance as a viable option."

    Frustrated, Ehdaie and his colleague, Andrew Vickers, a biostatistician, decided to consult with Deepak Malhotra, a Harvard Business School professor who specializes in difficult negotiations. "It was a very left-field idea to say let's use behavioral economics to help a doctor explain to a patient what is important," Vickers said. "But we knew that this was a problem and that surgeons weren't dealing with it. Doctors often use the completely wrong words."

    3 ways to negotiate with patients

    After observing Ehdaie consult with patients, Malhotra used his business school negotiation techniques to create three main recommendations for providers:

    1. Prioritize active surveillance: Malhotra advised Ehdaie to flip the order in which he presented treatment options to his patients so that instead of discussing surgery, radiation, and only then touching on active surveillance, Ehdaie started the conversation with active surveillance so as to make it the "default option." Malhotra said, "Instead of going on and on about surgery, and then going on and on about radiation, you give the prominence and salience to active surveillance."

    2. Reframe the timeline: Malhotra also recommended that instead of telling patients that they would come in for a check-up every six months—a framing that made many patients concerned their cancer would spread between visits—Ehdaie tell patients that while their cancer was growing slowly enough that a five-year wait between appointments would be safe, he would like to see them every six months. The reframing, Lagnado writes, helped some patients feel as if their cancer was being closely tracked.

    3. Provide messaging: Lastly, Malhotra advised Ehdaie to give patients a brief outline of the situation that they could use when discussing the diagnosis and treatment options with family members and friends who might "start questioning" the decision to opt for active surveillance.


    Ehdaie said after he incorporated Malhotra's advice, nearly all his patients began opting for active surveillance over other treatments. In turn, Ehdaie launched a study on the process to assess whether the approach could be taught to other providers, and whether implementing the approach improved active surveillance rates at Memorial Sloan.

    For the study, Ehdaie and Malhotra taught five surgeons the recommendations in a one-hour lecture, then compared the decisions of 1,003 patients eligible for active surveillance. The study found that the rate of patients who opted for active surveillance increased from 69 percent in the two-year period before doctors took the negotiation class to 81 percent afterwards. In other words, according to the the study, "the risk of unnecessary curative treatment" dropped 30 percent.

    And James Eastham, chief of the urology service at Sloan Kettering, said since his department began implementing Malhotra's strategies, active surveillance rates for prostate cancer "have increased significantly." According to Eastham, about 90 percent of patients eligible for the approach now opt for active surveillance (Lagnado, Wall Street Journal, 9/2).

    Change how you communicate with patients

    Excellent patient experience is a critical piece of modern medicine, reflected clearly in outcomes. And more than amenities, clean rooms, or quiet during night, the factors that most inflect patient experience all relate to communication and coordination among the care team—factors that physicians are in a unique position to influence.

    Clinician-patient communication, leadership of the care team, and support and empathy for the patient across the unit are the most important factors for success, and they’re all driven by the physician as the “Influencer in Chief.”

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