Editor's Choice

Decisions, decisions . . .

BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c6236 (Published 03 November 2010) Cite this as: BMJ 2010;341:c6236
  1. Jane Smith, deputy editor, BMJ
  1. jsmith{at}bmj.com

At a trivial level I’ve always found too much choice disabling: too many types of pasta sauce on the supermarket shelves and I’ve walked away empty handed. So if choice can be disabling as well as enabling, it’s important that “choice” in the serious matter of healthcare is well managed and supported. This week’s BMJ offers lots of evidence on choice and how to support it.

Angela Coulter reviews what we know about giving patients more choice over their healthcare, against the background that the government in England wants to increase their choices (doi:10.1136/bmj.c4989). In general, she says, patients like the idea of choice and respond to offers of options of where to be treated (even though their providers don’t always make those options clear). Patients don’t make much use of performance data in choosing between clinical providers, but they do want more involvement in choosing their actual treatment. Coulter says that use of evidence based decision aids improves patients’ knowledge, understanding of options, and perception of risks and can reduce demand for surgical procedures, but that UK patients rarely get effective support to make their treatment decisions. One barrier is clinicians’ unwillingness to offer such support.

This reluctance is also dealt with by Glyn Elwyn and colleagues (doi:10.1136/bmj.c5146). They too look at the evidence on shared decision making and describe a pilot project in the east of England where patients are given access to online decision support on osteoarthritis of the knee, benign prostatic hypertrophy, and prostate cancer at the point when they need to decide on their treatment. This pilot aside, the authors say that much more research has gone into creating the decision aids themselves than into creating a culture where professionals espouse shared decision making as a skill and routinely use the tools. “Professionals often claim that there is no need for this approach because shared decision making already occurs, but the available evidence contradicts this … 48% of inpatients and 30% of primary care patients would have liked more involvement in decisions about their care.”

An Australian study by Sian Smith and colleagues shows a decision aid in action (doi:10.1136/bmj.c5370). They randomised people with a low level of education and literacy to receive either standard information about screening for bowel cancer (by faecal occult blood testing) or one of two variants of a decision support aid. The people using the decision aid showed greater knowledge, made a more informed choice, and had less decisional conflict than the people who didn’t—and fewer of them decided to take the test.

This last finding dismays our editorialist, Hilary Bekker (doi:10.1136/bmj.c5407). She quotes the authors’ speculation that this result was due to the way risks were represented in the decision aid. She then suggests that in the context of bowel cancer screening the facts might be better structured to facilitate adherence with testing—“a policy of informed uptake rather than informed decision making.”

I wonder if the many authors of one of our letters would agree. Michael Baum and colleagues write on behalf of a large group who in February last year wrote to the Times calling for the UK’s breast cancer screening leaflet to be rewritten because “none of the invitations for screening told the truth about its harms and benefits” (doi:10.1136/bmj.c6152). Despite a promise from the national cancer director that a review of the guidance would result in a new leaflet in the autumn, the new leaflet has not appeared.


Cite this as: BMJ 2010;341:c6236


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