Shared decision-making in medicine

Shared decision-making in medicine is a process in which both the patient and physician contribute to the medical decision-making process and agree on treatment decisions. Health care providers explain treatments and alternatives to patients and help them choose the treatment option that best aligns with their preferences as well as their unique cultural and personal beliefs. SDM has also been described as a method of care.
In contrast to SDM, the traditional biomedical care system placed physicians in a position of authority with patients playing a passive role in care. Physicians instructed patients about what to do, and patients rarely took part in the treatment decision.

History

One of the first instances where the term shared decision-making was employed was in a report on ethics in medicine by Robert Veatch in 1972. It was used again in 1982 in the "President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research". This work built on the increasing interest in patient-centredness and an increasing emphasis on recognising patient autonomy in health care interactions since the 1970s. Some would even claim that a general paradigm shift occurred in the 1980s in which patients became more involved in medical decision-making than before.For example, a 2007 review of 115 patient participation studies found that the majority of respondents preferred to participate in medical decision-making in only 50% of studies prior to 2000, while 71% of studies after 2000 found a majority of respondents who wanted to participate.
Another early and important driver for shared decision-making came from Jack Wennberg. Frustrated by variations in health care activity that could not be explained by population need or patient preference he described the concept of unwarranted variation, which he attributed to varying physician practice styles. A key means of reducing this unwarranted variation was to recognise "the importance of sound estimates of outcome probabilities and on values that corresponded closely to patient preferences". Shared decision-making would allow patient preferences and values to determine the right rate of healthcare use. The Dartmouth Institute for Health Policy and Clinical Practice consequently made shared decision-making a key element of their program of work.
Charles et al. described a set of characteristics of shared decision-making, stating "that at least two participants, the clinician and patient be involved; that both parties share information; that both parties take steps to build a consensus about the preferred treatment; and that an agreement is reached on the treatment to implement". This final element is not fully accepted by everyone in the field. The view that it is acceptable to agree to disagree is also regarded as an acceptable outcome of shared decision-making.

Patient autonomy and informed consent

SDM relies on the basic premise of both patient autonomy and informed consent. The model recognizes that patients have personal values that influence the interpretation of risks and benefits differently from the way a physician interprets them. Informed consent is at the core of shared decision-making, i.e. without fully understanding the advantages and disadvantages of all treatment options, patients cannot engage in making decisions. But there is frequently more than one option, with no clear choice of which option is best, especially when the decision at hand is about a preference-sensitive condition. Shared decision-making differs from informed consent in that patients base their decisions on their values and beliefs, as well as on being fully informed. Thus in certain situations the physician's point of view may differ from the decision that aligns most with the patient's values, judgments, opinions, or expectations about outcomes.

Factors that predict participation

is a field related to shared decision-making but which focuses more specifically on the patient's role in the patient-physician relationship. There are certain patient characteristics that influence the extent of their participation. One study showed that female patients who are younger and more educated and have less severe illnesses than other patients are more likely to participate in medical decisions. That is, more education appears to increase participation levels and old age to reduce it. Another study found that age was not inversely related to participation levels but that patients who are not as fluent with numbers and statistics tended to let their physicians make medical decisions. Culture also makes a difference. In general, for example, Americans play a more active role in the physician-patient relationship, such as by asking follow-up questions and researching treatment options, than do Germans. In one study, Black patients reported that they participate less in shared decision-making than white patients, yet another study showed that Black patients desire to participate just as much as their white counterparts and are more likely to report initiating conversation about their health care with their physicians.
Individuals who place a higher value on their health are more likely to play a passive role when it comes to medical decision-making than those who placed a lower value on health. Researchers Arora and McHorney posit that finding may be the result of their apprehension when it comes to health-related concerns among those who place a high value on health, leading to a tendency to let an expert, rather than themselves, make important medical decisions.
There is mounting evidence that giving patients real-time, unfettered access to their own medical records increases their understanding of their health and improves their ability to take care of themselves. Study results indicate that full record access enables patients to become more actively involved in the quality of their care, such as following up on abnormal test results and determining when to seek care. Providing patients with ready access to their doctors' visit notes has proven to have a positive impact on the doctor-patient relationship, enhancing patient trust, safety and engagement. Patients with access to notes also show greater interest in taking a more active role in the generation of their medical records. The adoption of open notes has recently been recommended by the Institute of Medicine, as a means of improving diagnostic accuracy via patient engagement.
Other studies have shown that the strongest predictors of patient participation are not characteristics of the patients themselves but are specific to the situation, such as the clinical setting and the physician's style of communicating. Frequent use of partnership-building and supportive communication by physicians has led to facilitating greater patient engagement. In the context of mammography screening, physicians' message delivery styles such as how they articulated relative versus absolute risk numbers had also influenced patients' perceptions towards shared decision-making.
Generally, physicians engage in more patient-centered communication when they are speaking with high-participation patients rather than with low-participation patients. Also, when a patient consults with a physician of the same race, the patient perceives that physician as involving them more than a physician of a different race.

Models of SDM

OPTION model

Elwyn et al. described a set of competences for shared decision-making, consisting of the following steps a) defining the problem which requires a decision, b) the portrayal of equipoise providing information about the attributes of available options and d) supporting a deliberation process. Based on these steps, an assessment scale to measure the extent to which clinicians involve patients in decision-making has been developed and translated into Dutch, Chinese, French, German, Spanish and Italian.

Three-talk model

Another model proposes three different "talk" phases: team talk, option talk and decision talk. First, clinicians work to create a supportive relationship with the patient as they introduce the idea of recognizing the existence of alternative actions —this is to form a team with the patient and their family. Second, the clinician introduces the options in a clear way, describing and explaining the probabilities of benefits and harms that might be likely—this is option talk. In the last phase, patients' preferences are constructed, elicited and integrated—this is decision talk. A shorter five-item version of the OPTION scale has been published based on this model.

Interprofessional model

More and more care is delivered not by individuals but by interprofessional healthcare teams that include nurses, social workers, and other care providers. In these settings, patients' health care decisions are shared with several professionals, whether concurrently or consecutively. The interprofessional shared decision-making model is a three-level, two-axis framework that takes this complexity into account. Its three levels are contextual influences at the individual level, influences at the systemic or organizational level, and influences at the broader policy or social level. The axes are the SDM process and the different people involved. While interacting with one or more health professionals and family members, the patient moves through a structured process including explanation of the decision to be made; information exchange; eliciting values and preferences; discussing the feasibility of the options; the preferred choice versus the decision made; planning and implementing the decisions; and outcomes. Since this model was validated in 2011, it has been adopted in rehabilitation, dementia care, mental health, neonatal intensive care, hospital chaplaincy and educational research, among other fields.

Ecological model

Measures of patient participation can also be used to measure aspects of shared decision-making. The ecological model of patient participation, based on research by Street, includes four main components of patient participation. The first is information seeking, measured as the number of health-related questions the patient asks along with the number of times the patient asks the physician to verify information. The second component is assertive utterances. e.g. making recommendations to physicians, expressing an opinion or preference, or expressing disagreement. The third component is providing information about symptoms, medical history and psychosocial factors, with or without prompting from the physician. The final component of patient participation is expressions of concern, including affective responses such as anxiety, worry, or negative feelings. The extent of participation can be determined based on how often a patient displays these four overarching behaviors.