Thursday, September 9, 2010

So What Exactly Do You Mean By "Shared Decision Making?" It Turns Out It May Be More Complicated

Just what is medical "shared decision making" (SDM)? Is it when the doctor explains and the patient decides? Or, is it when the doctor decides after the patient explains? Something in between? Neither? Well, thanks to Alexander Kon writing about the topic in the Aug. 25 JAMA, the Disease Management Care Blog has a better appreciation of how complex the issue can be.

Dr. Kon notes that definitions of SDM seem to span a continuum between two extremes. On one end is the patient calling all the shots, while on one end, the physician is doing so. In between are various degrees of sharing that can be categorized as a) "physician recommendation," b) true equal partners and c) "informed non-dissent."

In physician recommendation, the patient ultimately makes the decision, but it's up to the doctor to try to objectively list all the options in a neutral manner. On the other end, in informed non-dissent, the physician ascertains the patient's values, lists the options but makes the decision while allowing the patient to veto it. When there are true equal partners, both parties work together to reach a mutually satisfactory decision.

Good point, says the DMCB. Next time you hear the term "shared decision making" from a colleague, co-worker, supervisor, boss or speaker, you may need to ask them if they're talking about the variants that tilted toward the doc (informed non-dissent) or toward the patient (physician recommendation) or truly in the middle. You may be surprised at the answer.

1 comment:

c3 said...

When I was teaching residents, my believe was we were a long way from "shared decision making". With this in mind I was most interested in "baby steps".

So my push was to ask two specific questions as the doc was approaching conclusion and recommendations (i.e. Assessment and Plan)

-What do you believe is going on that's causing these symptoms? (or some similar question)
-What do you think would be most helpful in managing these symptoms?

My main point was that (and research indicated) if one didn't solicit patient input on what was going on and what to do they (the patients) were less likely to adhere to your recommendation. And since medicine not taken is "bad" medicine, not seeking this input was "bad medicine"

I don't think there's much reinforcement of such an approach "out there" in the "real world"