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Patient centred diagnosis: sharing diagnostic decisions with patients in clinical practice

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4218 (Published 01 November 2017) Cite this as: BMJ 2017;359:j4218
  1. Zackary D Berger, associate professor of medicine1,
  2. Juan P Brito, assistant professor of medicine2,
  3. Naykky Singh Ospina, assistant professor of medicine3,
  4. Suraj Kannan, medical student1,
  5. Jeremiah S Hinson, instructor of emergency medicine1,
  6. Erik P Hess, professor of emergency medicine2,
  7. Helen Haskell, president4,
  8. Victor M Montori, professor of medicine2,
  9. David E Newman-Toker, professor of neurology, ophthalmology, and otolaryngology1
  1. 1Johns Hopkins University School of Medicine, Johns Hopkins Outpatient Center, 601 N Caroline St Suite 7143, Baltimore, MD 21287 US
  2. 2Mayo Clinic, Rochester, MN, USA
  3. 3Division of Endocrinology, University of Florida School of Medicine, Gainesville, FL, USA
  4. 4Mothers Against Medical Error
  1. Correspondence to: Z D Berger zberger1{at}jhmi.edu

Shared decision making for diagnostic decisions is understudied and differs from treatment decision making. Zackary D Berger and colleagues discuss how uncertainty and stakes should shape the conversation

Key messages

  • Patient centred diagnosis is best practised through shared decision making; an iterative dialogue between doctor and patient, which respects a patient’s needs, values, preferences, and circumstances

  • Shared decision making for diagnostic situations differs fundamentally from that for treatment decisions. This has important implications when considering its practical application

  • The nature of dialogue should be tailored to the specific diagnostic decision; scenarios with higher stakes or uncertainty usually require more detailed conversations

In 2001, the National Academy of Medicine set out its vision to prioritise patient centred care: to ensure that clinical decisions “respect patients’ wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care.”1 Similar aims also exist in UK health strategy.2 Patient centred care is best delivered through patient-clinician relationships that foster shared decision making; an approach that has been shown to encourage health promoting behaviours, reduce inappropriate or unnecessary use of care, and improve patient and clinician satisfaction.345

Shared decision making and diagnosis

Shared decision making goes beyond simple information exchange: it emphasises collaborative, often iterative, deliberation between patients, family, and clinicians, to advance the desired outcomes identified by the patient (fig 1⇓).678910

Fig 1 Conceptual model of patient centred diagnosis. Clinical context includes the presenting patient concern, the clinician’s role, and the clinical setting. Considering this and the patient’s (or family’s) overall goals of care, a dialogue between clinician and patient or family should be used to agree on a patient centred diagnostic plan.

This deliberation should cover patient preferences that are global (such as the patient’s capacity and …

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