Commentary
Re-thinking shared decision-making: Context matters

https://doi.org/10.1016/j.pec.2013.01.006Get rights and content

Abstract

Objective

Traditional perspectives on shared decision-making (SDM) focus attention on the point in a clinical encounter where discussion of a treatment decision begins. We argue that SDM is shaped not only by initiation of a treatment decision, but also by the entire clinical encounter, and, even more broadly, by the nature of the patient–provider relationship.

Method

The Four Habits Approach to Effective Clinical Communication, a validated and widely used framework for patient–provider communication, was used to understand how SDM is integrally tied to the entire clinical encounter, as well as to the broader patient–provider relationship.

Results

The Four Habits consists of four categories of behaviors: (1) invest in the beginning; (2) elicit the patient's perspective; (3) demonstrate empathy; and (4) invest in the end. We argue that the behaviors included in all four of these categories work together to create and maintain an environment conducive to SDM.

Conclusion

SDM cannot be understood in isolation, and future SDM research should reflect the influence that the broader communicative and relational contexts have on decisions.

Practice implications

SDM training might be more effective if training focused on the broader context of communication and relationships, such as those specified by the Four Habits framework.

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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