When planning any type of medical treatment, interactions between the patient and their clinical care team tend to fall into one of the following types: paternalistic, informative, or shared decision-making.
Paternalistic decision-making occurs when the physician decides which course of action or treatment is in the patient's best interest, without involving the patient in the decision-making process, i.e., “Here’s what we’re going to do for you Mrs. Smith.”
The “Informative” approach to decision-making provides the patient more comprehensive information including pros and cons, and the risk of complications, but still does not consider the patient’s values or preferences.
Shared decision-making occurs when the health care provider and patient work together to make a health care decision that is best for the patient. The optimal decision takes into account evidence-based information about the available treatment options, the clinician’s knowledge and experience, and any factors the patient values in their decision-making. The patient brings their preferences, goals, lifestyle, support structure, etc. – whatever they feel is important in making a decision. The surgeon brings evidence-based information and their expertise. Together, they find the “sweet spot” in the middle. Shared decision-making involves a lot more than just explaining the risks of a procedure and also incorporates the biological, sociological and psychological factors the patient brings to the table.
Most patients prefer a collaborative approach over deferring treatment decisions to their doctor. Unfortunately, in many cases patients may be reticent to initiate this type of conversation or simply don’t appreciate that they can. In reality, if the clinician doesn’t subscribe to shared decision-making, it simply won’t happen unless the patient advocates for themselves.
A recent study published in the PMC U.S. National Library of Medicine, National Institute of Health, showed that “…approximately 40% of breast cancer patients do not fulfill their preferred role in their treatment decision and this…has been associated with decisional conflict…delay in treatment initiation, decisional regret, poorer quality of life, and decreased treatment satisfaction.” Shared decision-making provides an opportunity to do better across all medical specialties and disease states.
Access to health information on the Internet and via social media is changing the patient’s role in healthcare. Increasing time constraints are leaving patients getting less face-to-face time with their docs and patients are having to research more on their own. People are therefore advocating for themselves more and wanting to become more involved in their health care decisions than ever before. Increasingly, people want to be equal contributors to discussions about their healthcare.
Multiple studies across several medical and surgical specialties show shared decision-making offers many benefits to both the patient and physician:
- Improves patient education
- Decreases patient anxiety
- Decreases decisional conflict
- Helps set appropriate patient expectations for the patient
- Improves patient satisfaction
- Improves patient outcomes
Decreasing decisional conflict means the patient is less likely to seek a second opinion because of insecurity, and it also decreases medical malpractice risk. Improving patient outcomes and satisfaction can also create extremely positive secondary effects on the surgeon’s practice from a marketing perspective. Happy patients can be very effective advocates for a specific procedure or the entire practice. Shared decision-making is also intrinsically quite rewarding. In addition to being effective and ethical, it enables the delivery of high quality, patient-centered care.
The SHARE approach provides physicians with a simple five-step outline for a shared decision-making doctor-patient interaction:
Step 1 - To begin the interaction, the clinician must gage the level of interaction the patient wants and is comfortable with. However, it is important to acknowledge that a new diagnosis can make people vulnerable and insecure. Assuming — or even imposing — patient autonomy can lead to an underestimation of the patient’s vulnerability and an overestimation of their ability to make good decisions. In some cases, an appeal on autonomy can therefore be a burden. The main goal of shared decision-making is not to always have patients make autonomous choices, but to provide high quality patient-centered care based on the level of involvement the patient is seeking.
The various treatment options and associated risks are reviewed during step 2.
Step 3 defines the patient’s priorities by listening to what’s important to them. Let’s use the example of a patient diagnosed with breast cancer who is interested in reconstruction: what do they need to make the reconstruction process worthwhile for them? Are they merely seeking to be able to wear a bra, or do they expect to look better than before in a bikini? How do they feel about implants? How do they feel about scars? How important is sparing the nipple-areola? Do they know the mastectomy will likely rob them of most, if not all, of their breast sensation? How important is sensation to them?
Step 4 involves discussing how the patient’s preferences favor certain options while taking the overall clinical picture into account. Patients may hold a view that one option fits their lifestyle and values better than another. This view may be different from the clinician’s. Shared decision-making recognizes the patient’s right to make these decisions, ensuring they are fully informed about the options they face, and the likely consequences both short- and long-term.
Step 5 is assessment of the treatment plan. Is the plan medically appropriate and reasonable? Some people will need more time to think about things (e.g., talk to their family/work), and that of course is absolutely ok!
While shared decision-making has many benefits, unfortunately it has not been widely adopted by the medical community. Reasons include the lack of training in this approach, the perception that it takes too much time to perform, and fear of potentially losing the patient if the doctor doesn’t offer all the treatment options. It is therefore extremely important that patients advocate for themselves to ensure their voices are heard during their treatment planning, regardless of their medical diagnosis.
Dr. Minas Chrysopoulo is an internationally-recognized breast reconstruction surgeon and shared decision-making advocate, and the creator of the Breast Advocate App, the only shared decision-making app for breast cancer surgery and breast reconstruction.