Intended for healthcare professionals

Letters National shared decision making

Shifting the focus of shared decision making to human relationships

BMJ 2018; 360 doi: (Published 08 January 2018) Cite this as: BMJ 2018;360:k53
  1. Jonathon P Tomlinson, GP
  1. The Lawson Practice, London N1 5HZ, UK
  1. echothx{at}

Leng and colleagues discuss efforts to improve shared decision making.1 The main barriers lie in medical culture, primarily a result of the “hidden curriculum” where traditional patriarchy trumps enlightened behaviour almost all of the time.

Inspiring, worthy, and passionate writing has long implored us to do more shared decision making, exponentially in the past decade—from Peabody’s The Care of the Patient in 1927 to David Werner’s Where There is No Doctor (a manual for village healthcare workers) in 1987 and Emmanuel and Emmanuel’s 1992 paper on four models of the doctor-patient relationship.

If we want to see shared decision making become anything other than the obsession of academics, paywalled journals (oh the irony), and enlightened clinicians, we need a paradigm shift from care that is centred on biology, diseases, patients, or doctors to one that is centred on human relationships with an understanding of how power operates.

Structural factors that undermine relational continuity of care—including increasing specialisation and subspecialisation, increasing use of technicians and assistants, e-health, loss of hospital firms, shorter work placements, and part time practitioners—all mitigate against relationship centred care, but without such care shared decision making isn’t going to get very far at all.


  • Competing interests: None declared.


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