Keeping the patient in the center: Common challenges in the practice of shared decision making

Kimberly A Fisher; Andy S L Tan; Daniel D Matlock; Barry Saver; Kathleen M Mazor; Arwen H Pieterse

doi:10.1016/j.pec.2018.08.007

Keeping the patient in the center: Common challenges in the practice of shared decision making

Patient Educ Couns. 2018 Dec;101(12):2195-2201. doi: 10.1016/j.pec.2018.08.007. Epub 2018 Aug 6.

Authors

Kimberly A Fisher¹, Andy S L Tan², Daniel D Matlock³, Barry Saver⁴, Kathleen M Mazor⁵, Arwen H Pieterse⁶

Affiliations

¹ Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA; Meyers Primary Care Institute, A joint Endeavor Between the University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA. Electronic address: Kimberly.Fisher@umassmemorial.org.
² Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
³ Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA; VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO, USA.
⁴ Swedish Family Medicine Residency Cherry Hill, Seattle, WA, USA; Department of Family and Community Medicine, University of Massachusetts, Worcester, MA, USA.
⁵ Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA; Meyers Primary Care Institute, A joint Endeavor Between the University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA.
⁶ Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands.

Abstract

Objective: To examine situations where shared decision making (SDM) in practice does not achieve the goal of a patient-centered decision.

Methods: We explore circumstances in which elements necessary to realize SDM - patient readiness to participate and understanding of the decision - are not present. We consider the influence of contextual factors on decision making.

Results: Patients' preference and readiness for participation in SDM are influenced by multiple interacting factors including the patient's comprehension of the decision, their emotional state, the strength of their relationship with the clinician, and the nature of the decision. Uncertainty often inherent in information can lead to misconceptions and ill-formed opinions that impair patients' understanding. In combination with cognitive biases, these factors may result in decisions that are incongruent with patients' preferences. The impact of suboptimal understanding on decision making may be augmented by the context.

Conclusions: There are circumstances in which basic elements required for SDM are not present and therefore the clinician may not achieve the goal of a patient-centered decision.

Practice implications: A flexible and tailored approach that draws on the full continuum of decision making models and communication strategies is required to achieve the goal of a patient-centered decision.

Keywords: Decisional agency; Healthcare setting; Patient engagement; Shared decision making.

Publication types

Research Support, U.S. Gov't, P.H.S.

MeSH terms

Communication*
Comprehension*
Culture
Decision Making*
Delivery of Health Care
Female
Humans
Male
Patient Participation*
Patient Preference
Patient-Centered Care*
Physician-Patient Relations
Uncertainty

Grants and funding

K08 HS024596/HS/AHRQ HHS/United States