When prescribing medical treatments, a physician must strike a careful balance. On the one hand, physicians must not neglect to treat patients who need medical help. On the other hand, physicians must not prescribe treatments that are unlikely to be beneficial or go against the patient’s wishes. The delicate nature of this situation requires a physician to understand all relevant factors, ranging from hard medical facts to available treatment options to the patient’s values and beliefs. In recent years, physicians have weighed the possibility of shared decision-making (SDM) during medical care, a specific paradigm of healthcare that deliberately fosters collaboration and deliberation between physician and patient [1]. Clinical research has studied the effectiveness of SDM and developed a set of best practices for this new technique.
Pediatrician and bioethicist Dr. Alexander A. Kon describes the tradeoff between physician-centric and patient-centric decision-making as a continuum [2]. Patients can bear more responsibility by treating the physician as an adviser, while the patient becomes the ultimate decision-maker. Physicians can bear more responsibility by practicing informed non-dissent, where a course of action is chosen for the patient provided that (a) the patient has all relevant information about the course of action, and (b) the patient does not directly dissent against it. The practice of SDM can encompass these scenarios, or it can refer to a third scenario, in which patient and physician share roughly equal responsibility. Regardless, Kon writes, SDM requires time and communication skills, especially active listening, so that the physician can fully understand the patient’s perspective.
In practice, medical providers might implement shared decision-making through the following three-step process. This process occurs after some amount of conversation that leads to a physician understanding the patient’s situation, including arrival at a diagnosis. First, the physician primes the patient to make choices about treatment by increasing awareness that choices do exist and that the patient can make them. Second, the physician describes treatment options to the patient, outlining the benefits and harms without bias toward any one option. Third, the physician focuses on the patient’s preferences and values, helping them move toward a decision best aligned with those values. This SDM model proved relatively successful across 86 randomized trials. Generally, patients exhibited higher decision-making confidence, elected conservative treatment options, and became more consistent with their actual preferences [3]. Although researchers are generally optimistic, a wider breadth and depth of studies would increase the credibility of SDM. In addition, the development of thorough, effective training for clinicians will be necessary.
The literature on behavioral psychology suggests that humans often fail to behave as rational agents. These findings have many implications for shared decision-making and other clinical decision-making paradigms. First, patient preferences can be inconsistent over time and in different scenarios [4]. These preference inconsistencies are difficult to work with: How can a physician assess the patient’s preferences if they change between appointments? Second, the literature on choice architecture suggests that the mere framing of a set of options can bias a decision-maker [5]. How can a physician avoid these biases when they are mandated to communicate treatment options to the patient? These findings about human behavior should inform current and future paradigms of clinical decision-making, especially where multiple parties are involved, as well as areas in which further research is needed.
References
[1] J. T. Clapp, et al Surgical Overtreatment and Shared Decision-making—The Limits of Choice. JAMA Surgery 2021. DOI:10.1001/jamasurg.2021.4425.
[2] A. A. Kon. The Shared Decision-Making Continuum. JAMA 2010. DOI:10.1001/jama.2010.1208.
[3] G. Elwyn, et al. Shared Decision Making: A Model for Clinical Practice. Journal of General Internal Medicine 2012; 27: 10. DOI:10.1007/s11606-012-2077-6.
[4] E. F. MacDonald, et al. Preference Inconsistency in Multidisciplinary Design Decision Making. Journal of Mechanical Design 2009; 131: 3. DOI:10.1115/1.3066526.
[5] R. H. Thaler, et al. Choice Architecture. In The Behavioral Foundations of Public Policy, ed. E. Shafir. Princeton University Press 2013.
