Shannon Brownlee’s recent post, “Don’t discard shared decision making on the basis of PSA testing,” couldn’t ring more true. The crux of shared decision making is that the patient must decide, with his or her physician, which tests or procedures make sense, given the various risks, tradeoffs and outcomes. Discarding the construct on the basis of one test (PSA testing) is not only poor form in that it is a sample of one, but also what might not seem like much of a choice to some may be the biggest choice of all to someone else.
Choice is the operative word in this debate. Patients need to know their options, regardless of physician opinion or what research says would probably happen (i.e. a false positive). It is up to the patient to choose whether the odds are worth it to them. And while PSA testing may not be strong in validity (though the research does conflict), causing some doctors to (erroneously, in my opinion) consider it non-elective, there are certainly other common medical tests that warrant shared decision making, such as colon cancer screening, for example. In addition to the decision of whether or not to be tested there are several choices about how to get tested and then after that several choices about what to do in the event that a polyp is found. When medical evidence supports more than one approach to testing, patients should be informed about their choices and providers should respect their preferences.
Shared decision making is not just the right thing to do, it is one of the most effective ways to combat the myriad health issues affecting us today – quality, cost, satisfaction. Shared decision making is not meant to encourage or discourage certain tests or procedures – it is meant to involve and educate each patient so that no medical choice is made without them. And that makes patients happy – exercising the right to be involved in decisions about their care. Once educated, patients do tend to select less invasive procedures on average, as Shannon notes, and costs thereby go down as does the risk of medical error or unwanted care. A randomized controlled trial in the New England Journal of Medicine also produced these effects: a shared decision making intervention produced 9.8% fewer inpatient and outpatient surgeries and 11.5% fewer hospital admissions.
Shared decision making makes healthcare better. To my fellow physicians trying to determine whether to test or not to test – include the patient first. Is the patient involved? That is the real first question.
Peter Goldbach is Chief Medical Officer, Health Dialog.
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