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Shared decision-making in medicine
Shared decision-making in medicine (SDM) is a process in which both the patient and physician contribute to the medical decision-making process and agree on treatment decisions. Health care providers explain treatments and alternatives to patients and help them choose the treatment option that best aligns with their preferences as well as their unique cultural and personal beliefs. SDM has also been described as a method of care.
In contrast to SDM, the traditional biomedical care system placed physicians in a position of authority with patients playing a passive role in care. Physicians instructed patients about what to do, and patients rarely took part in the treatment decision.
One of the first instances where the term shared decision-making was employed was in a report on ethics in medicine by Robert Veatch in 1972. It was used again in 1982 in the "President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research". This work built on the increasing interest in patient-centredness and an increasing emphasis on recognising patient autonomy in health care interactions since the 1970s.[non-primary source needed] Some would even claim that a general paradigm shift occurred in the 1980s in which patients became more involved in medical decision-making than before.[non-primary source needed] For example, a 2007 review of 115 patient participation studies found that the majority of respondents preferred to participate in medical decision-making in only 50% of studies prior to 2000, while 71% of studies after 2000 found a majority of respondents who wanted to participate.
Another early and important driver for shared decision-making came from Jack Wennberg. Frustrated by variations in health care activity that could not be explained by population need or patient preference he described the concept of unwarranted variation, which he attributed to varying physician practice styles. A key means of reducing this unwarranted variation was to recognise "the importance of sound estimates of outcome probabilities and on values that corresponded closely to patient preferences". Shared decision-making would allow patient preferences and values to determine the right rate of healthcare use. The Dartmouth Institute for Health Policy and Clinical Practice consequently made shared decision-making a key element of their program of work.
Charles et al. described a set of characteristics of shared decision-making, stating "that at least two participants, the clinician and patient be involved; that both parties share information; that both parties take steps to build a consensus about the preferred treatment; and that an agreement is reached on the treatment to implement". This final element is not fully accepted by everyone in the field. The view that it is acceptable to agree to disagree is also regarded as an acceptable outcome of shared decision-making.[non-primary source needed]
SDM relies on the basic premise of both patient autonomy and informed consent. The model recognizes that patients have personal values that influence the interpretation of risks and benefits differently from the way a physician interprets them. Informed consent is at the core of shared decision-making, i.e. without fully understanding the advantages and disadvantages of all treatment options, patients cannot engage in making decisions. But there is frequently more than one option, with no clear choice of which option is best, especially when the decision at hand is about a preference-sensitive condition. Shared decision-making differs from informed consent in that patients base their decisions on their values and beliefs, as well as on being fully informed. Thus in certain situations the physician's point of view may differ from the decision that aligns most with the patient's values, judgments, opinions, or expectations about outcomes.
Patient participation is a field related to shared decision-making but which focuses more specifically on the patient's role in the patient-physician relationship. There are certain patient characteristics that influence the extent of their participation. One study showed that female patients who are younger and more educated and have less severe illnesses than other patients are more likely to participate in medical decisions. That is, more education appears to increase participation levels and old age to reduce it. Another study found that age was not inversely related to participation levels but that patients who are not as fluent with numbers and statistics tended to let their physicians make medical decisions. Culture also makes a difference. In general, for example, Americans play a more active role in the physician-patient relationship, such as by asking follow-up questions and researching treatment options, than do Germans. In one study, Black patients reported that they participate less in shared decision-making than white patients, yet another study showed that Black patients desire to participate just as much as their white counterparts and are more likely to report initiating conversation about their health care with their physicians.
Individuals who place a higher value on their health are more likely to play a passive role when it comes to medical decision-making than those who placed a lower value on health. Researchers Arora and McHorney posit that finding may be the result of their apprehension when it comes to health-related concerns among those who place a high value on health, leading to a tendency to let an expert, rather than themselves, make important medical decisions.
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Shared decision-making in medicine
Shared decision-making in medicine (SDM) is a process in which both the patient and physician contribute to the medical decision-making process and agree on treatment decisions. Health care providers explain treatments and alternatives to patients and help them choose the treatment option that best aligns with their preferences as well as their unique cultural and personal beliefs. SDM has also been described as a method of care.
In contrast to SDM, the traditional biomedical care system placed physicians in a position of authority with patients playing a passive role in care. Physicians instructed patients about what to do, and patients rarely took part in the treatment decision.
One of the first instances where the term shared decision-making was employed was in a report on ethics in medicine by Robert Veatch in 1972. It was used again in 1982 in the "President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research". This work built on the increasing interest in patient-centredness and an increasing emphasis on recognising patient autonomy in health care interactions since the 1970s.[non-primary source needed] Some would even claim that a general paradigm shift occurred in the 1980s in which patients became more involved in medical decision-making than before.[non-primary source needed] For example, a 2007 review of 115 patient participation studies found that the majority of respondents preferred to participate in medical decision-making in only 50% of studies prior to 2000, while 71% of studies after 2000 found a majority of respondents who wanted to participate.
Another early and important driver for shared decision-making came from Jack Wennberg. Frustrated by variations in health care activity that could not be explained by population need or patient preference he described the concept of unwarranted variation, which he attributed to varying physician practice styles. A key means of reducing this unwarranted variation was to recognise "the importance of sound estimates of outcome probabilities and on values that corresponded closely to patient preferences". Shared decision-making would allow patient preferences and values to determine the right rate of healthcare use. The Dartmouth Institute for Health Policy and Clinical Practice consequently made shared decision-making a key element of their program of work.
Charles et al. described a set of characteristics of shared decision-making, stating "that at least two participants, the clinician and patient be involved; that both parties share information; that both parties take steps to build a consensus about the preferred treatment; and that an agreement is reached on the treatment to implement". This final element is not fully accepted by everyone in the field. The view that it is acceptable to agree to disagree is also regarded as an acceptable outcome of shared decision-making.[non-primary source needed]
SDM relies on the basic premise of both patient autonomy and informed consent. The model recognizes that patients have personal values that influence the interpretation of risks and benefits differently from the way a physician interprets them. Informed consent is at the core of shared decision-making, i.e. without fully understanding the advantages and disadvantages of all treatment options, patients cannot engage in making decisions. But there is frequently more than one option, with no clear choice of which option is best, especially when the decision at hand is about a preference-sensitive condition. Shared decision-making differs from informed consent in that patients base their decisions on their values and beliefs, as well as on being fully informed. Thus in certain situations the physician's point of view may differ from the decision that aligns most with the patient's values, judgments, opinions, or expectations about outcomes.
Patient participation is a field related to shared decision-making but which focuses more specifically on the patient's role in the patient-physician relationship. There are certain patient characteristics that influence the extent of their participation. One study showed that female patients who are younger and more educated and have less severe illnesses than other patients are more likely to participate in medical decisions. That is, more education appears to increase participation levels and old age to reduce it. Another study found that age was not inversely related to participation levels but that patients who are not as fluent with numbers and statistics tended to let their physicians make medical decisions. Culture also makes a difference. In general, for example, Americans play a more active role in the physician-patient relationship, such as by asking follow-up questions and researching treatment options, than do Germans. In one study, Black patients reported that they participate less in shared decision-making than white patients, yet another study showed that Black patients desire to participate just as much as their white counterparts and are more likely to report initiating conversation about their health care with their physicians.
Individuals who place a higher value on their health are more likely to play a passive role when it comes to medical decision-making than those who placed a lower value on health. Researchers Arora and McHorney posit that finding may be the result of their apprehension when it comes to health-related concerns among those who place a high value on health, leading to a tendency to let an expert, rather than themselves, make important medical decisions.