Supporting patients to make the best decisionsBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2117 (Published 07 April 2011) Cite this as: BMJ 2011;342:d2117
- Martin Marshall, clinical director and director of research and development,
- Jo Bibby, director of improvement programmes
Imagine an intervention designed to improve patient care that a systematic review has shown to be effective, does not seem to have any serious unwanted effects, has been a central component of health policy for more than a decade, is popular with patients, and which in principle is embraced by most clinicians.
Surprisingly, perhaps, an intervention that meets these criteria does exist, in the form of shared decision making. This is a process in which patients are encouraged to participate in selecting appropriate treatment or management options on the basis of the best available evidence.
For many years policy makers in the United Kingdom have advocated a stronger role for patients, most recently in the NHS constitution,1 and as a central part of the current health reforms, in which “nothing about me without me” has become a defining mantra.2 Other countries are equally committed to the agenda. In December 2010 a group of 58 international healthcare leaders and researchers published the Salzburg statement on shared decision making, calling for a stronger commitment to what they call “co-production of health.”3 To mark the signing of the Salzburg statement on shared decision making the BMJ brought together 14 doctors, patients, academics, and policy makers to discuss how to involve patients in decisions about their health. In the linked feature article Anne Gulland reports the outcomes of the discussion.
The evidence in favour of shared decision making is reasonably strong, particularly when compared with that supporting most initiatives aimed at changing behaviour. The systematic review includes the results of 55 randomised controlled trials conducted over the past 25 years.4 It shows that patients involved in shared decision making are better informed than those who are not, and that they are less likely to be undecided about the best course of action at the end of a consultation. Patients are also more likely than their doctors to defer or decline surgical intervention, with no measurable adverse impact on health outcomes or satisfaction, and with the potential to reduce costs. Patients also seem more likely to adhere to treatment regimens and less likely to sue their doctor.
Given this evidence base and the sustained support from policy players it is surprising that shared decision making is not yet a standard feature of clinical practice. Although most clinicians claim that they involve patients in decisions, evidence suggests otherwise. Video analysis of consultations has shown that clinicians are often poor at even eliciting, never mind acting on, the patient’s agenda.5 The most recent national patient survey suggests that one in three patients in primary care and one in two patients in hospital would have liked greater involvement in decisions about their care.6
There is clearly a gap between aspiration and reality and the reasons for this are complex. The evidence cited in favour of shared decision making relates primarily to the effectiveness of a specific set of tools called decision aids, and many clinicians find them difficult to use within the constraints of routine consultations.7 In addition, although the evidence underpinning their use is convincing in terms of improvements in the consultation process, there is currently little evidence that they improve clinical outcomes for patients.4 Some clinicians are not convinced that the overall benefits to patients outweigh the effort required to change their established routines.8
But the explanation is probably more fundamental. Shared decision making is a concrete manifestation of a more substantial social process, the re-conceptualisation of the roles and responsibilities of patients and health professionals in improving health. This is challenging territory. Although clinicians are traditionally seen as the dominant player in the consultation, the interaction is increasingly being framed as a meeting between two experts.8 9 The clinician brings an understanding of the effectiveness, benefits, and harms of specific actions and the patient brings an understanding of their preferences and their attitudes to illness and risk. Shared decision making is therefore deeply counter cultural. It challenges the belief that professionals know what is best for the patient, and that patients are not able to understand complex information and are not emotionally ready to make decisions.10 It also challenges the view of patients that their doctor or nurse is usually making the best decision, an assumption that research increasingly shows is inaccurate.11 Finally, it challenges the ways in which the health system operates to deliver established patterns of practice, rather than being designed to encourage a different dynamic between patients and professionals.
Promoting shared decision making is increasingly seen as something that is needed to keep pace with changing societal expectations. It is time to move beyond isolated examples of good practice to the implementation of principles and practices at scale.8 Although a focus on technical tools such as decision aids is useful, it is clearly not enough.
Achieving widespread culture change requires an alignment of a range of different approaches across the whole system. The challenge for practitioners is to change attitudes and introduce new skills, and it is therefore largely an educational one. This should take place at all stages of professional development, and patients should play an active role in the educational process. Those responsible for designing and managing services need to tackle the practical constraints that inhibit shared decision making, particularly time and ease of access to high quality evidence. The implementation of standards and incentive schemes may also play a useful role in creating a culture in which purposeful shared decision making becomes the norm.
Most fundamentally, the ability to share decisions with patients must be seen as a core component of what it means to be a health professional,12 with the professional role changing from experts who care for patients to enablers who support patients to make decisions.
Cite this as: BMJ 2011;342:d2117
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.