Shared decision making is a necessary concept in modern patient care

There’s nothing better than sitting down with a patient, going though an entire visit, and collaborating on a well thought out plan that meets everyone’s expectations.

Shared decision making is a wonderful and necessary concept in modern patient care. Paternalistic attitudes are fading away in the medical community as the next generations of doctors continue to get educated on how to manage patients who are very knowledgeable and yearn to be active participants in their care.

But as patients become more involved in the decision making process, differences in opinion become more prominent. Although these differences can be overcome through open discussion and trust, it is a challenge that is occurring with regularity. In this era of short pressured visits, it’s hard to have long conversations to help meet the patient in the middle when there is a difference in opinion. Litigation concerns also influences decision making immensely, and when there is a debate about whether “to test,” or “not to test,” we might be inclined to align our opinions more towards what a patient wants.

When a patient adamantly wants something done, and I rationally disagree, it can be a disheartening experience. I reflect on how I’ve spent years studying, training and practicing. I think about how I’ve spent years, not just memorizing facts, but cultivating clinical acumen that integrates multiple data points to compute probabilities of disease states and figuring out likelihood ratios of different tests or medicines and whether the benefits greatly outweigh potential harms and costs. And I have to do this within seconds to minutes in my head, while factoring in patient preference and medico-legal concerns. I do this juggling act countless times a day, and when I’m wrong it hurts. It hurts my ego a little bit. But it hurts more because you always want what’s best for the patient.

I’m sure we all have stories of things we regretted ordering for our patients. I can think of several instances of how I acquiesced to a patient’s request that resulted in poor outcomes. Antibiotics that I didn’t want to give, leading to C. Diff colitis, imaging with incidental findings that lead to unnecessary worry, procedures and complications are just a few examples. I can also think of many instances where patients have come to me with positive test results or better outcomes from things I was reluctant to do.

Whether you are for or against shared decision making, it is here to stay. Patients want to have to more say in their care and that’s a wonderful thing. Involved patients will always do better than detached ones. The modern physician will need a balanced temperament to handle the ups and downs of this two way relationship. Fortunately my ego is just big enough that I return to work every day smiling, feeling good about all my good decisions. But I do keep my ego in check, mainly by taking some Tums tablets. I’ve realized my heartburn isn’t caused by the coffee I drink, but all the pride I’m willing to swallow and the large heaping servings of humble pie medicine serves me with regularity.

Shabbir Hossain is an internal medicine physician who blogs at  Shab’s Sanatorium.

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  • Steve Wilkins

    Good post.

    Shared decision-making is certainly receiving a lot of attention in the health literature these days, usually in the context of care planning as you point out.

    But it would seem that shared decision-making should also be taking place up front with respect to agreeing upon the “visit agenda.”  The literature indicates that in as many as 70% of primary care visits, the patient’s agenda is not being fully elicited by physicians. 

    People, me included, go to the doctor with very specific concerns/fears that we expect to be able to discuss with out doctors.  Often the patient’s get overlooked in favor of the provider’s agenda.  While this phenomenon may not occur with patients in your practice, your patients have probably experience it in other practices…and these previous experiences need to be considered.

    Patients are being asked to take on more responsibility for the care, including things like share-decision-making.  That’s fine…and patients will be amenable to that if 1) they know that that’s their role in the “new health care reality” and 2) someone takes the time to teach them when and how to do it.  Remember, for the past 80 years patients have be socialized to be speak only when asked.  Many expect you the doctor to make the decision….not ever having been given a choice to express an opinion by their other doctors. 

    Just as physicians have to learn how to involve patients in shared decision making…patients have to be taught why and how to get involved. 

    Steve Wilkins 

  • karen3

    ” I think about how I’ve spent years, not just memorizing facts, but cultivating clinical acumen that integrates multiple data points to compute probabilities of disease states and figuring out likelihood ratios of different tests or medicines and whether the benefits greatly outweigh potential harms and costs.”  
    No matter how much you know and how much you compute, you will never know the whole sum of a patient’s life — the finances, the family situation, the employment situation, what their personal history is, etc.   And those are all factors that go into what is the “right” answer for a patient.  All that you learned and know is only PART of the considerations.  So, you should have no ego about what the patient’s final decision is, as long as it is within the broad realm of what is medically reasonable.  It’s not about you.  

    Every single professional has clients who don;t agree with the advice given. The “professional” part of the job is being able to handle that graciously, understanding that if you try to bully people into doing things they don’t want to do, they won’t be asking you for your opinion ever again.  My guess is that the bulk of docs who have “non-compliance’ issues also are bullies. 

  • TheFeministBreeder

    I greatly appreciate providers who can graciously accept that some patients actually have preferences in what happens to their body. I see so often in maternity care: Providers push a certain practice because it may seem “easier” to them. They want to schedule that cesarean for 39 weeks instead of letting the mother start labor on her own. They don’t understand when the patient refuses. They think, “who cares how the baby gets out.” But that OB doesn’t go home with that large uterine scar, deal with the weeks of recovery, and the perhaps lifelong reproductive consequences of having that scar. The doctor thinks the patient is just being a pain, but the patient has a whole life they need to consider before signing up for a major surgery. The doctors who can respect their patients are the doctors who will excel in this new climate.

  • arnold

    So, what do you do, when you share a decision with a patient, that you know in your heart of hearts is the proper decision, and another physician debunks your opinion, and does something inappropriate? This happened to me a few weeks ago, to the detriment of the patient.

  • James

    I am willing to forgo my paternalistic approach but is everything that my father did for me of no value growing up? I wanted an unlimited curfew. Is shared parental-child decision making next? I would like to see the data of improved outcomes from shared decision making. Speaking of shared decision making, if I suggest decreasing alcohol intake, a healthier diet and more exercise but my patient “decides” not to. Do I agree with his or her decision? With shared decision making comes consequences. Are we ready for this?

  • katerinahurd

    Do you think that shared decission making will reveal the futility of certain medical treatments and restore the right of patients to choose how his life might end?

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