Shared decision-making: It’s no longer ‘doctor knows best’

Does this sound familiar? You go to the doctor. They diagnose you and tell you what the treatment will be. The end.

This one-sided approach to decision-making involves the doctor dictating care without much, if any, input from the patient. But this is now beginning to change. We’re moving away from that sort of “doctor knows best” model of medical decision-making and toward a newer approach known as shared decision-making.

We’ve moved away from a “doctor knows best” model of decision-making and moved toward shared decision-making. via @MedStarWHC

Here’s the big idea:  I have expertise in medicine. You have expertise in you. Shared decision-making recognizes the expertise of patients and empowers them to engage in the medical process. This is illustrated in the principle “Nothing about me without me.”  

Shared decision-making provides numerous benefits to patients. One review of 105 studies compared patients who received usual care with those who used decision aids, which are tools designed to facilitate shared decision-making. These tools can include written materials, videos or interactive web-based programs. The review found that patients who used decision aids felt more knowledgeable and confident in decisions, better understood the benefits and risks of treatment options and had a greater likelihood of receiving care aligned with their values.  

As patients increasingly play a more active role in their health care, learn how shared decision-making works and how you can take an active role in it. But first, let’s look at a hypothetical situation to see how shared decision-making can influence your treatment.  

What shared decision-making looks like in practice

You come to the hospital after having a small heart attack. You’re stable but have blocked arteries. We discuss your condition and treatment options, which include medication and bypass surgery.  

Often, I’d recommend surgery for a patient with blocked arteries. But if you’re unable to be off work for the eight weeks it will take to get back to full function after bypass surgery or you serve as the primary caregiver for an elderly parent, we may be able to delay surgery and discuss alternatives.

There’s no confrontation or hard feelings. Rather, it’s a negotiation about the interaction between a medical recommendation and your personal situation. Instead, we may tailor your medications to your situation, discuss warning signs of which to be aware, and send you home with the understanding that we may discuss surgery again in the future.  

This situation illustrates how shared decision-making is meant to work. The doctor and patient have an open, honest conversation and a decision is reached based on the perspective of both parties.  

How shared decision-making works

Shared decision-making may sound like common sense. And it is. Unfortunately, medicine got away from this type of doctor-patient collaboration as quality measures focused on enforcing care guidelines.  

In the past, if you came in with high cholesterol, quality care was defined as you leaving with a prescription for a statin – whether you wanted one or not. It didn’t matter if you didn’t understand why, didn’t agree, or threw the prescription in the garbage the second you left the doctor’s office. By gosh, the guidelines said to give you a statin, so the doctor gave you a statin.  

No one wants to have decisions made for them, or to have their thoughts and opinions not taken into consideration. We now consider quality treatment to be achieved if three steps have been followed:

  • The doctor explains the treatment options
  • The doctor and patient have a thoughtful discussion about each one
  • A decision is reached that is right for the patient

In this meeting between the doctor and the patient:

  • The doctor contributes knowledge about the condition and treatment options
  • The patient contributes their past experiences, preferences, goals and values, along with information they have from research about their condition and treatment options  

In a perfect world, the doctor’s recommendation and patient’s wishes align. But sometimes they don’t, and in those cases, we come up with another plan. Or maybe we decide it’s not right today, but we keep the topic open and talk about it later.  

I find that patients usually have valid reasons for why they don’t want to follow certain treatments. “I tried it in the past and it didn’t work.” “A friend did it and it didn’t turn out well.” “My family doesn’t think I should do it.” “My primary care doctor disagrees.”  

At the end of the day, I want my patients to feel comfortable with their care decisions. To do that, doctors need to sit down at the table and talk with you eye to eye – not stand up and dictate what you should do. We need to encourage patients to open up by asking questions and listening to the answers:

  • Do you understand your condition?
  • What do you think about the treatment recommendation?
  • Is it right for you, and if not, how can we make it right for you?
  • What are your concerns?  

Your role and responsibility in shared decision-making

Shared decision-making is a two-way street. The doctor must be willing to involve you and respect your expertise and preferences, but you also must take an active role in the process.

  • Learn about your condition and treatment options: Listen to your doctor and read the information they give you. You also can do your own research before or after appointments.
  • Speak up: Ask questions when you don’t understand something. Share your concerns, goals and preferences.  
  • Recruit family or friends to help: Needing medical care can feel overwhelming. Sometimes it helps to have a loved one with you as a second set of eyes and ears. They can take notes to help you remember details later and ask questions you may think of later.  

The first step toward making a medical decision is to fully understand your options. While each condition is different, here are a few questions to ask to get started:

  • What are my treatment options?
  • What are the risks and benefits of each?
  • What is the goal of each option? Is it to treat the condition or improve the symptoms?
  • How will each treatment make me feel?
  • What are the side effects and how will they affect my quality of life?  

When you and your doctor actively collaborate on care, you’re more likely to feel confident and satisfied in your decisions. Find a doctor who engages in shared decision-making, and play your role in it as well.  

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Taylor

Allen J. Taylor, MD, FACC, FAHA, is chief of cardiology at MedStar Heart & Vascular Institute, including MedStar Georgetown University Hospital and MedStar Washington Hospital Center in Washington, D.C. In his 20-year United States Army career at Walter Reed, Dr. Taylor served as director of cardiovascular research, director of the Cardiovascular Disease Training Program and chief of the cardiology service. He retired from military service in 2008 at the rank of Colonel, held the Army’s “A” proficiency designator and was decorated with the Legion of Merit. He is professor of medicine at the Uniformed University of the Health Sciences, and Georgetown University.

Dr. Taylor’s major research accomplishments include defining the role of lipid lowering therapy on carotid atherosclerosis, focusing on HDL cholesterol and the use of niacin. His pioneering work in the field of cardiac CT includes conducting long-term prospective outcomes trials, randomized clinical trials on the utility of the technique, and methods to enhance the safety and appropriateness of cardiovascular imaging. He has published four books and more than 180 manuscripts in journals such as Circulation, Journal of the American Medical Association and New England Journal of Medicine.

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