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July 25, 2019

Realizing Shared Decision-making in Practice

Author Affiliations
  • 1Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland
  • 2Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
JAMA. 2019;322(9):811-812. doi:10.1001/jama.2019.9797

Shared decision-making (SDM) is integral to clinical practice. In medical training, clinicians are encouraged to engage patients in SDM so that clinical care is consistent with patients’ values and preferences. Professional societies and other groups generating screening and treatment guidelines specifically recommend SDM. In 2015, reimbursement from Medicare for lung cancer screening was made contingent on SDM.1

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    4 Comments for this article
    Ethical and Good Practice
    Edward Schor, MD | Stanford School of Medicine
    Shared decision-making is certainly recommended on ethical grounds, but there are practical underpinnings to that activity. Previous research on shared decision-making has shown that it increases patients' adherence to the treatment plans and thus improves clinical outcomes. When patients' outcomes are less than expected, physicians who have not truly partnered with patients and have not provided appropriate self-management supports share responsibility for poor outcomes.
    Enlightened SDM
    R Reginald, MA | OCC
    Shared Decision Making is a concept whose time has come. However, to some patients, medical terminology is analogous to ancient Latin. One needs to know that he/she has truly communicated the options available in terms understandable to patients. Towards this end, the physician might consider recommending videos which are made of surgical (or other) procedures done by personnel (doctors, PA’s, nurses) at one’s facility. (Obviously, permission would be obtained from the patient on which the procedure was performed and filmed.) These videos could be made available for the prospective patient to view. The video would show all aspects of the procedure from prep through recovery. After viewing the video, the patient would then be truly informed re his/ her proposed procedure. Patient concerns could then be formulated and addressed based upon patient knowledge of what would actually happen at that facility. The mystique and fear would be eliminated, and the patient would actually know what was going to occur. Another benefit to these videos is that they virtually eliminate the possibility for the patient stating, "I wasn't informed regarding …." Are videos also a concept whose time has come?
    Shared Decision Making is Often Highly Dependent on Context and Venue
    Donald DeNucci, DDS | Research Consultant
    I learned late in my career as a dental surgeon that shared decision making is highly contextual and may not be appropriate in certain circumstances. As a staff periodontist in one of the nation’s largest health care systems, I was asked by my Service Chief early one morning to attend to the Chief of Cardiology’s painful and infected molar. The cardiologist arrived in the dental clinic both fearful and in significant pain. I seated him in the dental chair and administered local anesthesia which significantly reduced his discomfort. Feeling compelled to present my senior colleague with several treatment alternatives for his compromised tooth including extraction, I launched into a detailed discussion of each. My colleague politely stopped me and said, “I’m vulnerable right now and incapable of making a decision. Please do whatever you think is best of me”. I extracted the tooth. Our patients, regardless of their educational or socioeconomic status, expect that we possess the expertise and knowledge to make decisions that are in their best interests. This should not be ignored or forgotten in the rush to deploy “shared decision making” as an overarching maxim in clinical care. To do so is an abrogation of our responsibility to our patients.
    Shared Decision Making, To The Extent That Patients Desire, Should be Routine and Not an Add-on
    Andy Tan, PhD, MPH, MBA, MBBS | Dana-Farber Cancer Institute
    The suggestion in this Viewpoint that SDM should be prioritized for certain decisions and not others could be an impediment to realizing SDM in routine clinical practice rather than enhancing the practice of SDM. We need to create the normative expectation that offering SDM, to the extent that patients desire, is simply part and parcel of routine care, just as widely as we use the SOAP note (Subjective, Objective, Assessment, and Plan) to document history, signs, findings, and care. SDM should not be something special, optional, or an additional burden to the responsibilities of clinicians and providers. It is well within their duty of care owed to their patients to ensure that patients are involved in decisions about their care, as much as they wish to be involved, bringing together both clinicians' expertise of evidence-based care and patients' expertise of their own bodies as co-equal partners. Medical, nursing, PA and health professional training and also continuing education and accreditation could ensure that SDM is taught, assessed, and reinforced just as all other clinical skills are treated. By embedding SDM as a routine skill that is expected of all clinicians and providers, we will have a higher likelihood of achieving "No decision about me, without me" as the norm rather than the exception.