Norris Cotton Cancer Center

Helping Patients Make the Best Medical Decisions

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

June 15, 2009

"I want to feel confident my patients are makinggood decisions," says Dale Collins, MD, the newlynamed Director of the Center for Informed Choice at The Dartmouth Institute for Health Policy andClinical Practice (TDI). A plastic surgeon who specializesin breast reconstruction, Collins will bring aclinical perspective to the development and implementationof shared decision making for patientsfacing tough medical issues. "Patients receive bettercare when they take an active role in decisions abouttheir health. They need to be informed to make gooddecisions, and good decisions vary from patient topatient. Because patients have different values, thereis no right or wrong choice of treatment, but a bestchoice that is unique to each person," Collins says.

A researcher as well as a surgeon, Collins came toDartmouth in 1995 to study Outcomes Researchwith John "Jack" Wennberg, MD, founder of TheCenter for the Evaluative Clinical Sciences, nowknown as TDI. Collins earned her Masters of Sciencewhile practicing at Dartmouth-Hitchcock MedicalCenter. In 1999, she joined the Norris Cotton CancerCenter, as the Medical Director of the Comprehensive Breast Program, an interdisciplinaryclinic that integrates patient education materials withdecision-making aids for women diagnosed withbreast cancer. "It's difficult for patients to absorband integrate information, especially when theyhave just received a serious diagnosis. Patients needgood information to make good decisions, and theyneed time to absorb it." In her recent research, Collinshas proven that giving patients decision-makingtools that take into account a patient's values as wellas possible outcomes helps patients make the bestchoices on a case-by-case basis.

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

One of six centers of excellence at TDI, the Centerfor Informed Choice (CIC) is dedicated to makingpatients partners in care through shared decisionmaking and informed choice, which is decidedly notthe same as informed consent. The three main goalsof the CIC are: 1) to create pioneering educationalprograms about the theories, measurement methods,and research designs involved in studying shared decision making; 2) to investigatefundamental and applied research questions in keyaspects of the shared-decision making process; and 3)to design and test innovative clinical practice modelsthat incorporate shared decision making as an integralpart of care.

"Dartmouth is the only academic center in theworld with a hospital-based clinical and researchcenter for shared decision making," Collins says. Asdirector, she plans to promote research, to educatemedical students and clinicians, and to promote theresults of CIC's research to improve patient care andhealthcare policy.

Collins will be aided by co-director HilaryLlewellyn-Thomas, PhD, Professor in the Department of Community and Family Medicine, whospecializes in designing research projects and teachingresearch techniques to investigators. "While some ofthis research takes place in the laboratory and classroom,"Llewellyn-Thomas explains, "most of it takesplace in the clinical setting. It's great to have a clinicalleader like Dale to lead CIC. She really understandsthe importance of fostering individual-based,patient-sensitive, and rational approaches to decisionmaking. Changing systems and getting new informationand tools to patients require clinical championslike Dale, who are willing to rethink and redesignclinical work flow patterns to accommodate newideas in education, research, and practice."

Collins' work with the Comprehensive BreastCancer Program at the Cancer Center has made her a nationalleader in implementing a shared decision-makingprocess into comprehensive, coordinated patientcare. At CIC, Collins plans to build on that work."We need to do research around what are the rightquestions to ask: what's important for the patient tounderstand? How do we help people integrate theirpersonal values into their decision making? Our goalis to help patients make choices consistent with theirvalues-what's uniquely right for them." In her workas a surgeon, Collins has used Patients' DecisionAids-tools designed to help patients understandtheir disease and their own preference for treatmentbased on their thorough understanding of their corevalues along with the likely outcomes of the differentoptions available.

Several departments at DHMC already haveshared decision making processes in place for a varietyof choices patients face, ranging from decidingto undergo cancer-screening procedures to decisionsabout palliative care. A link from the Spine Center's web-page, for instance, leads to informational videosand DVDs available on loan, web-based decisionaids, and a healthcare decision guide for patientswith low back pain. Properly informed patients andtheir physicians can then decide on the best courseof treatment for a particular problem at a particulartime.

In addition to research, CIC's mission includestranslating results into the clinical setting, andinfluencing policy that will ultimately reward thoseclinicians who provide good information that helpspatients make the medical choices best for them.Collins looks forward to the day when a medical center'suse of a shared decision-making process becomesone of the measures of an institution's quality of care.