Should your doctor do all the talking?

MEDICAL MATTERS:What do we mean by shared decision-making?

" If you cannot make a diagnosis, at least make a decision."

– Sir Harry Platt (1897-1986)

THE NEW coalition government in the UK has proposed major changes in funding pathways for healthcare. Part of wide- ranging changes due to be implemented next April, there is to be a renewed emphasis on joint decision-making by patients and healthcare professionals.

What do we mean by shared decision-making? It is a process in which patients are encouraged to participate in selecting appropriate treatments or management options. It applies whenever there is more than one reasonable course of action. In clinical practice, there are often different ways to treat a health problem, each of which may lead to different outcomes. These are known as “preference-sensitive” decisions.

In theory, a patient- orientated approach is already the norm. Much training time is spent erasing any paternalistic tendencies in favour of a patient-centred approach, in which the healthcare professional acts as facilitator rather than dictator. But it’s not to every person’s taste; studies show about 30 per cent of patients want their doctor to make decisions on their behalf.

In response to the UK initiative, the medical journals have been debating the issue. A paper just published in the British Medical Journalsuggests that at least three conditions must be in place for shared decision-making to become part of mainstream clinical practice: ready access to evidence-based information about treatment options; guidance on how to weigh up the pros and cons of different options; and a supportive clinical culture that facilitates patient engagement.

For those of a cynical disposition, “supportive clinical culture” and the current models of care are incompatible. How can a doctor be facilitatory when he is expected to see up to 30 patients in a busy clinic, they ask. Give us more staff and more time and, sure, we’ll be as patient-centred as you want. However, others counter with examples of shared decision- making leading to cost reductions; a Cochrane review of decision aids found that, in some contexts, they could reduce rates of elective surgery by 25 per cent. They also point to a possible reduction in medicolegal costs, although there is, as yet, little evidence to support that contention.

Meanwhile, US-based analyst Angela Coulter asks “Do patients want choice and does it work?” It seems patients especially want treatment choices, but are less concerned about who provides medical treatment. In Coulter’s assessment, patients certainly want a greater involvement in choosing treatments and care. However, in her analysis, she points to evidence of reluctance by general practitioners to elicit patient preference and to facilitate shared decision- making. Coulter suggests there is a gulf between what patients say they want and what family doctors believe they want.

In practical terms, what is needed is the commissioning of high-quality decision support aids to allow patients to engage fully with what can be complex options. This will require dedicated funding – something that may prove challenging in these economic times. It certainly won’t be happening in the context of a €1 billion cut to our 2011 health budget.

Of course, like many other “good ideas”, shared decision- making is unlikely to be a panacea. A paper from the University of Edinburgh cites a lack of published evidence to show that a shared approach to the consultation improves patient recall. As a physician who has used audio recording of consultations in the belief that they help patient recall, this came as a bit of a shock.

How important is shared decision-making in medical care? It is certainly desirable in most healthcare consultations, although, as always in medicine, there will be some exceptions. And there is a need for additional research to help improve clinician performance in situations where patients express a preference for the doctor to decide on their behalf. Medical paternalism, however benign and informed, requires careful management if patient autonomy is to reach its full potential.

mhouston@irishtimes.com