Sir,

We would all agree that patients should receive information about their disease and its management. And, of course, they should decide whether or not they want to have a particular treatment. But, equally, we must be honest about the limitations to meeting these requirements.

At a time of serious financial constraints on the NHS, Stiggelbout et al. [1] enthusiastically promote shared decision making. Whilst they may wonder whether this will have resource implications, most of us could answer this question a priori. We do not need research to tell us that it will be time consuming and labour intensive; and that it will place a further burden on doctors or, alternatively, require armies of newly created experts – fresh from their weekend course in shared decision making – to be dispersed around the country extolling the virtues of their practice with missionary zeal. However, there are far more legitimate demands on shrinking budgets than shared decision making.

But what’s it all for? The authors concede that there is only limited evidence that shared decision making improves health outcomes. Instead, their case seems to rest on the somewhat dubious mixture of ethical considerations interspersed with claims of possible reductions in health care expenditure.

In any case, the current approach to shared decision making is simply pretence. In order to participate genuinely in their management, patients need to know much more than just the proportion of differently coloured, smiling faces on decision aids. Setting aside the education and experience necessary to cope with complex medical situations, the much touted graphical displays relating to the outcome of treatment focus solely on the numerical issues involved in understanding – an important aspect but only a fraction of what is required to appreciate the nature of the data. Surely patients should be told, for example, of the flaws in the research methods, of the influence of those with a vested interest in the outcome of the studies, of the data manipulation by researchers or policy-makers in order to present their case in the most favourable light, and of the possibility of fraud. [2]

Patient must also be informed that doctors and others who dispense information are not free from bias – for instance, there are financial incentives to diagnose and treat hypertension and raised cholesterol. And we need look no further than the patient booklets relating to breast and colorectal cancer screening to see how easy it is to mislead patients.

We must not fool ourselves into believing that what is proposed is tantamount to real shared decision making. It is, and probably will always be, lacking in too much to justify such a claim.

James Penston

james.penston@nhs.net

References

1. Stiggelbout AM, Van der Weijden T, De Wit MPT, et al. Shared decision making: really putting patients at the centre of healthcare. BMJ 2012;344;e256.

2. Penston J. Stats.con – How we’ve been fooled by statistics-based research in medicine. The London Press. London, November 2010.

Competing interests: None declared