How and why to use shared decision-making in practice

Shared decision-making (SDM) is a model for patient interactions that recognizes that patients have personal values and viewpoints that affect their interpretation of treatments' risks and benefits, and that this interpretation may be vastly different from their clinician's.

There are three basic components to SDM:

• Clear, accurate, and unbiased medical evidence about reasonable treatment alternatives (which can include no intervention), and the risks and benefits of each option.

• Clinician expertise in communicating this evidence, as well as in tailoring the evidence to the individual patient.

• Patient articulation of their values, goals, preferences, and concerns.

Primarily, SDM is a process to help make decisions when there are multiple options available and no clear “best choice.” When there is only one available option, or when there is a clear best option, SDM is not appropriate.

How do I use SDM in my practice?

The first step to SDM is to create a menu of reasonable options by narrowing the list of all possible options down to those that are reasonable for the specific patient in question. This is a step best undertaken by you, the clinician, alone (or, as a resident, with your medical team). Once the list of treatment options is narrowed, discussion with the patient about these options should then ensue.

One model for SDM, called the three-talk model, and described in an article in Patient Education and Counseling, proposes that discussion with the patient be thought of as three different “talk” phases.^[]

1. Team talk. The first phase of the discussion should set the stage by introducing the concept that there are multiple reasonable options for treatment; the discussion should strive to create a supportive relationship with the patient (and their caregivers) – that is, form a “team” that encompasses you (and/or your clinical team), the patient, and their family to make decisions together.

2. Option talk. During the second phase, the reasonable options for treatment should be presented by you in a clear and concise way that highlights the likely benefits and harms of each.

3. Decision talk. The final phase elicits patient preferences and integrates them into making the treatment decision.

SDM often relies on the use of tools called decision aids, which can help patients arrive at the best treatment decision.^[] Decision aids can be paper handouts, videos, or interactive media (apps). Remember, however, that decision aids are meant to supplement SDM, not take its place.

Why use SDM?

SDM discussions do take up time and energy, two things that are often quite limited during residency. So, why use SDM when making treatment decisions?

Studies have shown that patients who participate in SDM are more likely to feel a greater sense of self-efficacy and more secure about their treatment choice, which in turn facilitates a stronger sense of commitment to recover.

Patients who participate in decision-making with their clinician increase their frequency of self-management and self-care behaviors (which include both disease-specific management strategies and overall health behaviors).^[]

Research has also shown that use of SDM leads patients to feel they are receiving better quality of care (and they therefore leave better healthcare reviews).^[]

Choosing SDM

The clinician needs to understand exactly where each patient is at the time of making treatment decisions, and meet them, whenever possible, where they are most comfortable.

Some patients may not want to make treatment decisions, but would rather you, as their clinician, make the decision for them. Other patients may find SDM difficult to participate in if you have been unable to engage with them emotionally, if they do not feel like a true part of the “team.”

This may take some further work on your part to engage them. In some cases, using creative solutions such as bringing in another team member with whom the patient does feel connected could help move the discussion along.

Ultimately, SDM is a practice that can help you become more connected with your patients, optimize treatment decision-making, and improve patient outcomes.