CommentaryRe-thinking shared decision-making: Context matters
Introduction
We argue in this commentary for an expanded view of shared decision-making (SDM). Using the Four Habits Approach to effective clinical communication [1], [2], [3], [4], [5], [6], we demonstrate that SDM is shaped by the entire clinical encounter – not just the point where a decision is made – and, even more broadly, by the nature of the patient–provider relationship (e.g., length, degree of alliance/trust). Our goal is to advance thinking about SDM, while challenging researchers to find more effective and innovative ways of studying this phenomenon.
Section snippets
SDM in health care
SDM has been widely advocated. Policy makers promote SDM because of its potential to increase use of beneficial treatment options, decrease utilization of treatment options without clear benefits, decrease variations in health care delivery, and promote patients’ involvement in their own health [7]. Philosophically, SDM is important because patients must live with the consequences of treatment decisions, including side effects, risks, benefits, and other effects on their day-to-day lives.
SDM and the entire clinical encounter
To study SDM effectively, the entire clinical encounter must be examined, not just the point when a decision is made. Indeed, no part of an interaction can be fully understood in isolation. What happens in the decision making process itself is inextricably linked to what happens before and after the decision. For example, if at the beginning of the visit a clinician uses a dominating, directive style with a patient, then later tries to involve the patient in a decision, the patient may be
Discussion
The study of SDM is replete with challenges. Not all SDM interventions have been effective [7], [52], and even widely used measures of SDM have had mixed support. In a recent study comparing two widely used SDM measurement tools, the OPTION scale and the Informed Decision Making instrument, there were generally low levels of agreement between the two tools [25]. Study authors suggested these findings might be attributable in part to the inherent difficulty in capturing and measuring SDM in
Funding
This work was funded by a Department of Veterans Affairs Health Services Career Development Award (CDA 10-034). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
Conflicts of interest
None.
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2018, Social Science and MedicineCitation Excerpt :These approaches entail a shift away from a paternalistic focus on achieving compliance with providers' instructions to the pursuit of concordance and respect for clients' autonomy and informed choice, even if this entails treatment rejection (Kremer et al., 2004). Reasons for the shift include cost-effectiveness; some evidence suggests that shared decision-making enhances treatment adherence and health outcomes (Coulter, 1997; Matthias et al., 2013). However, the evidence is not unequivocal and the shift is also ideological: treating patients and professionals as equals is seen as a moral ‘good’ (Pilnick and Dingwall, 2011).