Integrated decision making: definitions for a new discipline

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Abstract

The birth and early growth of a new discipline from the union of evidence-based medicine (EBM) and the theoretical foundations of human psychology and behaviour has led to a plethora of new terms to define and redefine a paradigm shift in clinical decision making. This paper provides a short glossary of (1) terms to describe the practitioner–patient relationship in decision making and (2) terms describing some of the tools for facilitating evidence-based decision making. In addition, it is proposed that a more acceptable name for this discipline may be ‘integrated decision making’ (IDM). A case is argued for the fact that this term better addresses many of the concerns raised by practitioners and consumers about barriers to the integration of evidence and patient preferences in clinical practice and the changing nature of the practitioner–patient relationship in healthcare today.

Introduction

The Evidence-Based Medicine Working Group’s seminal paper “evidence-based medicine” published in 1992 [1] met with praise and criticism from many sources [2], [3]. Despite strategies to facilitate the uptake of evidence into practice [4], [5], [6], the application of evidence within individual clinical decisions continues to be cited as problematic for practitioners [7], [8]. Attitudes to evidence-based medicine (EBM) are becoming more positive, but two of the main barriers practitioners face are: ‘a lack of time’ and ‘the need to tailor research to individual patient characteristics and preferences’ [7], [8], [9], [10]. It is at the point of clinical decision making, therefore, that quantitative ‘evidence’ meets psychological and behavioural theory and we need to understand the processes involved [11], [12], [13]. It appears that as these two worlds meet, a new discipline is being born—one that measures the quality of the processes that see evidence and patient preferences integrated into the partnership between individual patient and healthcare practitioner: “shared decision making” (SDM).

Like most new disciplines it is accompanied by a plethora of new terms that are often confusing for the newcomer. The need for clarification was apparent at the first Shared Decision Making Summer School in Oxford 2001, and prompted us to write this paper. It briefly summarises from the literature some of the most commonly used terms within this new discipline. These terms fall into two broad groups: (1) those that describe practitioner–patient relationships in decision making and (2) those that describe some of the tools being developed to facilitate evidence-based decision making by patients, practitioners or both. We conclude with a critical overview and argue for the consideration of a new term that more appropriately reflects the spectrum of health care decision making: “integrated decision making” (IDM).

Section snippets

Terms to describe the practitioner–patient relationship

The following terms are broadly synonymous and assume a partnership and flexibility in the ‘balance of power’ between practitioner and patient.

Tools to facilitate evidence-based decision making between practitioners and patients

The following list of tools is by no means complete but includes most of the common terms referred to in the literature on this subject.

“Integrated decision making”—a new term that best reflects a new discipline

As the “SDM” discipline develops it would be prudent to learn some lessons from the evolution of the EBM movement. Practitioners and patients want to be able to efficiently and effectively tailor evidence to individual circumstances and to incorporate patient preferences for maximal satisfaction and health outcomes [24], [31]. Although the SDM movement has the advantage of a greater understanding of the processes that can effectively integrate patient preferences and evidence into individual

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