The Truth About Shared Decision Making
The Truth About Shared Decision Making
Dr Velligan is Director, Division of Community Recovery, Research and Training; and Henry B. Dielman Chair, Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX.
Editor’s Note: We are pleased to present this summary based on Dr Velligan’s presentation at the 2017 Psychiatric Congress. She will be speaking on Saturday, September 16 at 9 am.
In the past several decades, clinical care has moved from a traditional provider-driven paternalistic model to one that values shared decision making (SDM). SDM is a process in which both the provider and the patient are involved, the provider shares information about the alternatives, risks, and benefits of specific treatments and elicits input from the patient; the patient shares information about his or her preferences, values, and concerns and ask questions; and both parties work toward an agreement on the treatment to be implemented.
A focus on understanding preferences and values of the patient is particularly central to treatment outcomes in situations in which there is no clear “best” treatment and there are many choices with variable adverse effect profiles. This is clearly the case in many areas of medical treatment including various cancers, diabetes, and psychiatric conditions.1-3 The Institute of Medicine calls for individuals’ values and preferences to guide all physical and mental health care.4
Empirical evidence indicates that involving patients in the treatment decision-making process leads to increased satisfaction with treatment, lower decision conflict arising from being better informed, better follow-through on treatment recommendations, and even improved outcomes for medical markers such as blood pressure and blood sugar.5,6
Despite its promise, it has been a slow process for SDM to be accepted in the mental health field relative to other areas of medicine. Provider-dominated decision making characterizes many psychiatric consultations. This may reflect provider concerns about the effects of mental illness on patients’ ability to participate in SDM. Many individuals with serious mental illness suffer from cognitive impairments that may hinder their ability for complex cognitive processing. Moreover, some psychiatric conditions specifically affect judgment and decision making. However, contradicting these apparent risks, many adults with serious mental illness frequently make competent and prudent treatment decisions.
To further complicate the picture, decision making for doctors and patients is subject to multiple biases. Prescribers have biases based on habit (comfort or lack of comfort with a specific option) and perceived risk aversion. Patients as human beings are subject to appraisal biases including ignoring information that does not fit into preconceived ideas, giving more weight to negative information, and being impacted by the context in which information is presented.1 Despite these pitfalls, patients routinely report wanting to be involved in decisions about their treatment.
Many providers believe they are engaging in SDM, but 6 out of 10 patients don’t feel listened to during appointments.7 Doctors are often missing the profound impact on the patient of the power differential. The patient is in the doctor’s office, on the doctor’s schedule. He or she is told when to enter and leave. If the patient is more than 15 minutes late the appointment is rescheduled. If a doctor is 15 minutes late, the patient is expected to wait. Staff have separate bathrooms. This context surrounding visits helps to create passivity and deference to the expert, even when the doctor believes SDM is taking place.8 Thus, it is necessary for the prescriber to engage in very specific behaviors to ensure that SDM is taking place.
According to Elwyn and colleagues,9 providers must engage in a number of steps to ensure that SDM is taking place, engages the patient, and offers hope. These include:
1. Choice talk, which involves making a statement that the two participants must think about what to do next, offering choices, emphasizing individual preferences
2. Option talk, which involves checking the patient’s knowledge, describing options in terms of harms and benefits, providing decision support and summarizing using the teach-back method
3. Decision talk, which involves eliciting a preference and moving to a decision.
Our research group has modified Elwyn’s model to include the responsibilities of the patient to Tell, Ask, Choose, and Review. Patient’s must tell the doctor important information about their condition and context, Ask key questions about options, Choose or choose to defer choice, Review the impact of their choice.
By training both providers and patients to engage in SDM using simple models focusing on specific behaviors, we may be able to increase the likelihood that SDM will take place in decision-making around treatment options in mental health.
1. Reyna VF, Nelson WL, Han PK, Pignone MP. Decision making and cancer. Am Psychol. 2015;70:105.
2. Seiber W, Newsome A, Lillie D. Promoting self-management in diabetes: efficacy of a collaborative care approach. Fam Syst Health. 2012;30:322.
3. Sepuvcha KR, Scholl I. Measuring shared decision making: a review of constructs, measures, and opportunities for cardiovascular care: Circulation. 2014;7:620-626.
4. Olsen L, Saunders RS, Young PL, Eds, for the Institute of Medicine Roundtable on Evidence-Based Medicine. The Healthcare Imperative: Lowering Costs and Improving Outcomes. Washington, DC: National Academies Press; 2005.
5. Roe D, Goldblatt H, Baloush-Klienman V, et al. Why and how people decide to stop taking prescribed psychiatric medication: exploring the subjective process of choice. Psychiatric Rehab J. 2009;33:366-374.
6. Joosten EA, DeFuentes_Merillas L, De Weert GH, et al. Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence, and health status. Psychother Psychosom. 2008;77:219-226.
7. Alston C. Shared Decision Making Strategies for Best Care: Patient Decision Aids. Washington, DC: National Academy of Medicine; 2014. https://nam.edu/perspectives-2014-shared-decision-making-strategies-for-best-care-patient-decision-aids/. Accessed August 29, 2017.
8. Gulbrandsen P, Clayman ML, Beach MC, et al. Shared decision-making as an existential journey: aiming for restored autonomous capacity. Pt Ed Counsel. 2016;99:1505-1510.
9. Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27:1361-1367.2012 ,