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Comment & Response
July 25, 2017

Nonclinical Factors Affecting Shared Decision Making—Reply

Author Affiliations
  • 1Center for Outcomes Research and Evaluation, Yale–New Haven Health, New Haven, Connecticut
  • 2Informed Medical Decisions Foundation, Healthwise Research and Advocacy, Boston, Massachusetts
JAMA. 2017;318(4):391-392. doi:10.1001/jama.2017.7865

In Reply We agree with Drs Smith and Volk that shared decision making should include discussions about the social and economic burdens of care associated with different treatment options. A multidisciplinary team can help enrich these discussions and ensure that patients are given meaningful information around which to base their decisions.

Yet to adequately address these social and economic factors in the shared decision making context not only requires a multidisciplinary team to elucidate patient capacities to adopt or adhere to different treatment options, it also requires that health systems be willing to invest in nonmedical services and in redesigning care delivery to meet patients’ capacities and goals.1 These concepts go beyond what is generally defined as shared decision making, with implications for informing its implementation and measurement. In the example used by Smith and Volk, a woman with breast cancer might prefer the more intensive treatment option but, as a single working mother with little social support, may not have the capacity to commit to this option. Flexible office hours and scheduling may be necessary to render the intensive treatment regimen a viable option for this patient. This expanded model of shared decision making that involves health system redesign and intervention may ultimately help support efforts to implement shared decision making into routine clinical practice, but it should be tested. Moreover, clear definitions of shared decision making, patient experience, and patient engagement are needed, along with considerations for whether clinicians and multidisciplinary teams should be held accountable for adjusting their approach for the different cultural, social, and economic factors that characterize populations.