The importance of Shared Decision Making

by | Aug 10, 2021

A recent article by Accenture titled “Digital adoption in healthcare: Reaction or Revolution?” published on August 6, 2021 pointed out the perceptions of 1800 patients of how they view their relationship with their doctors and the healthcare system since the onset of the Covid pandemic. Only 33% said that they have never had a negative experience with a medical provider, pharmacy, or hospital. Over two-thirds of patients were affected negatively, and of these, 44% said that the experience caused distress and upset. Most (55%) said a medical provider who explains a condition and treatment clearly is important for a positive experience.

52% said a medical provider who listens, understands their needs, and provides emotional support is important. An often-heard complaint is that physicians don’t spend enough time listening. One article reports that a physician will tend to interrupt their patient within 7 seconds of a conversation. Physicians may at times approach diseases through an algorithm approach based upon their training, experience and continuing education which attempts to fit the patient into a predetermined mold.

As a result, peripheral information which may be less important to the physician than to the patient can be marginalized or ignored. This then can result in frustration for both the physician and the patient as they are “talking past each other.” Error can occur as the physician attempts to confirm their initial impression of what is happening with their patient (confirmation bias), while focusing too rigidly on the initial impressions that they have.

When people are trying to make a decision, they often use an anchor or focal point as a reference or starting point. Psychologists have found that people have a tendency to rely too heavily on the very first piece of information they learn, which can have a serious impact on the decision they end up making. In psychology, this type of cognitive bias is known as the anchoring bias or anchoring effect. Confirmation bias is the tendency to search for, interpret, favor, and recall information in a way that confirms or supports one’s prior beliefs or values. Therefore, the ability to listen thoroughly and patiently is critical in understanding an individual’s wants and needs, and equally critical in avoiding error through bias. This leads to an understanding of the process of Shared Decision Making.

Key Points

  • Shared decision making (SDM) offers a structured process to incorporate evidence as well as patient values and preferences into screening decisions.
  • Shared decision making is most relevant when there is a close trade-off between the harms and the benefits of a screening decision that could be altered by individual patient values and preferences.
  • The core elements of SDM are risk communication and values clarification. Values clarification considers both patient values and patient preferences. Preferences are inclinations toward or away from an option. Values are the underlying feelings that help determine preferences.
  • Patient decision aids are knowledge translation tools that facilitate SDM, but individuals might require more than one office visit to arrive at a decision about screening.

Steps of SDM

Shared decision making involves the following steps of medical decision making, and a decision might require more than one visit.

Identify a clear decision point: Does the patient know and is the physician discussing the options for screening or treatment in a manner that takes into account the patient’s ability to understand and communicate?

At this step, both the patient and the clinician should ensure they understand and make explicit what the decision is about and what the options are.

Provide information about the clinical problem and options at the decision point.

This involves the provision of balanced, evidence-based information regarding the options under consideration. The information could include what the evidence tells us about both the good and the bad outcomes and over what time; the applicability of this information to individuals like the person who is making the decision; the robustness of the evidence, such as the extent of uncertainty around the estimate of effect; and the local availability of the options.

Elicit the patient perspective: Assess the patient’s view on what matters most.

Clinical teams play important roles in encouraging and supporting patients to become more active in health-related decisions. This is a learnable skill. Clinicians might wish to ask about any previous experiences, any related concerns, and more important, patient values and preferences regarding the different outcomes associated with the options under consideration.

Guide the patient toward a final decision.

This involves the challenge of providing guidance without being overly directive. In support of informed, value-based decisions on preventive health care, many clinicians will tell their patients about guideline recommendations. But a general recommendation about preventive health care is not targeted at specific individuals and their circumstances. Rather, it is based on the estimated benefits and harms across the entire target population. Clinicians should evaluate how the care of patients depends on their personal circumstances and yields choices that might not fit with any general recommendation.

Assess how comfortable the patient is with his or her decision.

At the end of the process, as a decision is made, the clinician can assess patient comfort with the decision by asking 4 brief questions, using the SURE screening test. This can help both clinician and patient understand how much the patient feels informed, clear about his or her values, and supported. A negative response to 1 of the 4 items will flag any remaining issues for further attention.

The SURE test: A response of yes scores 1 and a response of no scores 0; a score of Greater than 4 is a positive result for the patient to be at risk of clinically significant decisional conflict.

SURE ACRONYM

Sure of myself

Understand information

Risk-benefit ratio

Encouragement

TEST

Do you feel SURE about the best choice for you?
Do you know the benefits and risks of each option?
Are you clear about which benefits and risks matter most to you?
Do you have enough support and advice to make a choice?
The recognition of how patients experience the healthcare system offer important lessons to help both patient and their caregivers improve trust, experience, and outcomes for the benefit of all.

*Articles from Canadian Family Physician are provided here courtesy of College of Family Physicians of Canada

AMA

Grad R, Légaré F, Bell NR, et al. Shared decision making in preventive health care: What it is; what it is not. Can Fam Physician. 2017;63(9):682-684.

MLA

Grad, Roland et al. “Shared decision making in preventive health care: What it is; what it is not.” Canadian family physician Medecin de famille canadien vol. 63,9 (2017): 682-684.

APA

Grad, R., Légaré, F., Bell, N. R., Dickinson, J. A., Singh, H., Moore, A. E., Kasperavicius, D., & Kretschmer, K. L. (2017). Shared decision making in preventive health care: What it is; what it is not. Canadian family physician Medecin de famille canadien, 63(9), 682–684.

NLM

Grad R, Légaré F, Bell NR, Dickinson JA, Singh H, Moore AE, Kasperavicius D, Kretschmer KL. Shared decision making in preventive health care: What it is; what it is not. Can Fam Physician. 2017 Sep;63(9):682-684. PMID: 28904031; PMCID: PMC5597010.

Comment

0 Comments

Submit a Comment

Your email address will not be published.