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Shared decision-making: summary of NICE guidance

BMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n1430 (Published 17 June 2021) Cite this as: BMJ 2021;373:n1430

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Re: Shared decision-making: an ideal and an art.

Dear Editor,

Shared Decision Making (SDM) consists of aspects of evidence based medicine, communication, collaboration, decision making, building relationship… all based on the principle of autonomy of the patient: a complex process with each consultation as being unique (1). So SDM remains an ideal.

This explains why it remains uncertain whether any interventions for increasing the use of SDM by healthcare professionals are effective because the certainty of the evidence is low or very low. (Cochrane) (2). Likewise, the recommendations of the NICE panel are most based on moderate to very low randomized controlled trial evidence and the experience and opinion of the GC (3). The authors on the guideline panel mentioned patient decision aids but I also hoped to read the need for translation apps, which is also very important in a growing multicultural environment with a multitude of languages. (3)

In the learning process of SDM, the Calgary-Cambridge consultation model used most in undergraduate teaching has been honed and tested by experts over many years. But it comprises 73 items: long to be always helpful in a short interaction between doctor and patient. (4)

Identifying and eliciting ICE (Ideas, Concerns, Expectations) components of their patients by GPs are key competences related to shared decision making. For more than 20 years the ICE acronym has helped me to feed the whole process of SDM. (5) Hereby, it remains strange that ideas and concerns of patients were mentioned by the panel, but I could not read about the expectations or preferences of the patient. (3)

In terms of conversation, I like to compare my job as a GP with the work of the famous medieval Flemish painter Jan Van Eyck. In his time, Van Eyck had a revolutionary optics knowledge about the behavior and properties of light, including its interactions with matter and he felt wonderfully how he could almost physically display the light. He also used convex mirrors such as for the portrait of Arnolfini (National Gallery, London) (6) by which he compresses and expands the space at the same time. It is my job as a doctor to reveal, try to mirror and reflect on the Ideas, Concerns, Expectations of my patients, and this as a requisite for SDM.

The literature on SDM is exploding and informing and sharing decisions remain an art. Unfortunately, I am not a gifted artist-painter, but fortunately I may practice the healing art of medicine.

1. Elwyn G. Shared decision making: What is the work? Patient Educ Couns. 2021 Jul;104:1591-1595. doi: 10.1016/j.pec.2020.11.032. Epub 2020 Dec 1
2. Légaré F, Adekpedjou R, Stacey D. Interventions for increasing the use of shared decision making by healthcare professionals . Cochrane Database of Systematic Reviews 2018.
3. Shared decision-making: summary of NICE guidance BMJ . 2021 Jun 17;373:n1430. doi: 10.1136/bmj.n1430.
4. J Silverman, S Kurtz, J Draper - Skills for communicating with patients , 3th edition 2013 – book
5. Matthys J, Elwyn G, Van Nuland M, et al. Patients' ideas, concerns, and expectations (ICE) in general practice: impact on prescribing. Br J Gen Pract. 2009;59:29-36. doi: 10.3399/ bjgp 09X394833.
6. https://www.nationalgallery.org.uk/paintings/search-the-collection?q=Jan...

Competing interests: No competing interests

09 July 2021
Jan Matthys
General practitioner, vocational trainer, university of Ghent.
University of Ghent, Department of Primary Care and General Practice.
University Hospital, Corneel Heymanslaan 10, 9000 Gent, Belgium.
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