The Emerging Importance and Relevance of Shared Decision Making to Clinical Practice

Abstract

Since the President’s Commission first coined the term ‘‘shared decision making’’ over 30 years ago, it has been seen as an elusive ethical ideal in clinical practice. Clinicians have long misunderstood the ethical precept, confusing it with notions such as ‘‘Let the patient decide’’ and ‘‘Make sure you give the patient all the information possible’’ and bemoaning ‘‘How can I do this in a busy practice?’’ The emergence in the last 2 decades of empirical research examining patient-clinician communication in general and shared decision making in particular has fueled increasing interest in moving shared decision making from ethical ideal to actual practice. Many of these efforts have found voice in the growing movement to develop and deploy decision aids, products that help patients become more informed participants in decision making, and to reach decisions that are in line with their values, preferences, and life goals. Most recently, shared decision making as an expectation in practice was codified in the 2010 Affordable Care Act, which includes provisions to foster adoption of decision aids as well as to establish standards for decision aid quality and governmental support for their expansion. Despite these developments, we still have only spotty understanding of the degree to which shared decision making occurs in routine clinical practice. This issue of Medical Decision Making represents a high water mark for understanding shared decision making, with papers exploring these questions in more depth than ever before. The DECISIONS study marries the best methods of survey research and population sampling along with meticulous conceptualization of shared decision making, producing a series of papers that mark a significant advance in the understanding of the state of shared decision making in the United States. Among the conclusions that emerge from this important series of analyses is the observation that, confirming previous empirical research, although patients perceive themselves to be informed participants in medical decisions, their recall of the important factual information deemed critical to decision making was found to be lacking. Furthermore, what patients described as ‘‘participating’’ often equated to assenting to the recommendations of their physician without much discussion in the way of options or weighing of risks and benefits. Disturbingly, the DECISIONS investigators also found inferential evidence of racial bias in the manner in which African American patients were informed and invited to participate in certain clinical decisions. Unfortunately, none of these findings are new. From the original background research done by the President’s Commission to our own findings a decade ago, there is a stack of evidence that clinicians do a poor job in providing patients with sufficient, balanced information and an open invitation to participate in decision making. Over a decade ago, we analyzed audio recordings from over 1000 office visits and, using a valid and reliable measure of the quality of decision making, found that less than 10% of medical decisions met even the most minimal and lenient standards for shared decision making. These findings were striking because they were the result of direct observation, and thereby could not potentially benefit from the rose-colored glasses of patient recall, and have been replicated in other settings. Other investigators have shown marked racial differences in both patient perceptions of decision making and in the kinds of decisions clinicians make in simulated scenarios. From Stanford School of Medicine, Stanford, CA.