Research Articles
Shared decision making in clinical medicine: past research and future directions

https://doi.org/10.1016/S0749-3797(99)00097-5Get rights and content

Abstract

Content: Shared medical decision making is a process by which patients and providers consider outcome probabilities and patient preferences and reach a health care decision based on mutual agreement. Shared decision making is best used for problems involving medical uncertainty. During the process the provider-patient dyad considers treatment options and consequences and explores the fit of expected benefits and consequences of treatment with patient preferences for various outcomes. This paper reviews the literature on shared medical decision making. Several questions are considered. Although several studies suggest that patients do not want to be involved in decision making, these studies typically fail to separate decisions about technical aspects of treatment from preferences for outcomes. There is considerable evidence that patients want to be consulted about the impact of treatment. Studies on the acceptability of shared decision making for physicians have produced inconsistent results. Shared decision making is more acceptable to younger and better-educated patients. It remains unclear whether shared decision making requires expensive video presentations or whether the same results can be obtained with simpler methods, such as the decision board. We conclude that shared medical decision making is an important development in health care. More research is necessary to identify the effects of shared decision making on patient satisfaction and health outcomes. Further, more research is necessary in order to evaluate the most effective methods for engaging patients in decisions about their own health care.

Section snippets

Why shared decision making?

The classic view of the sick-role, as conceptualized by Parsons,8 sees the patient as exempted from his or her societal role by a physician. A sick patient attains this privilege by submitting to the physician’s directives. Following the prescribed course of treatment is expected to bring about relief and limit the time spent in the sick-role. According to this model, which has predominated medical treatment for many decades, the physician is dominant and autonomous and bears sole

Do patients want to engage in shared medical decision making?

A central question to the shared decision-making paradigm is whether patients actually want to participate in medical decision making. Several studies have addressed this question, and results of these studies have been mixed. A summary of these results appears in Table 1.

Cassileth and colleagues32 examined the extent to which cancer patients with varied diagnoses wanted to participate in treatment decisions. Most participants indicated a desire to participate in treatment decisions. However,

Do physicians want to engage in shared medical decision making?

A patient’s wish to participate in clinical decision making will have little impact if the physician is not open to the process. Despite the increasing shift toward patient-centered medicine in recent years,45 we were unable to locate studies that directly surveyed large samples of physicians regarding their views on shared decision making. While academic medicine espouses shared decision making as the clinical ideal, it is unclear how nonacademic physicians are inclined toward this paradigm.

How is shared decision making implemented and what are the results?

The basic preconditions to shared decision making between physician and patient have been outlined, but meeting these conditions may not always prove sufficient to confront the complexity of medical decision making. To date, limited research has focused on two areas: increasing a patient’s ability to engage physicians in a dialogue that facilitates shared decision making and providing patients with balanced reviews of treatment options and consequences.

Greenfield et al6 designed an intervention

Summary and future directions

There are a number of unresolved questions related to the implementation of shared decision making. The evidence regarding patient interest in decision making is mixed. Some studies have found little interest in shared decision making, while others find most patients desiring some control over decision making. The distinction between technical problem-solving issues and decisions that pertain to treatment outcomes is crucial in explaining the reluctance some patients have, but further research

Acknowledgements

Supported in part from a Scholars Grant from the American Cancer Society.

The authors gratefully acknowledge comments by Steven H. Woolf, MD, MPH, on an earlier draft of this paper.

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