Shared decision-making is problematic.  Clinical practice guidelines are increasingly recommending healthcare providers engage in shared decision-making prior to interventions.  It has been recommended for lung cancer screening¹, anticoagulation in atrial fibrillation², and hemoglobin A1c targets for diabetes³, to name a few.  Yet, these guidelines typically do not describe how to do this.  Incorporating individualized care plans with patients while navigating a busy practice is challenging.  Is shared decision-making even worth the effort?

The practice of medicine is complex.  We feel the pressure that comes with each additional demand on our already limited time.  We’ve had many years of advanced medical education, and we can understand the distinctions of how some patients might benefit from a given intervention while others might not.  We might even understand the intricate biostatistics that underlie the evidence.  But how can the average patient understand in a way that facilitates a meaningful conversation?  Perhaps this could be achieved with enough time but accomplishing this feat in a matter of minutes is daunting.

Granted, if I were the patient, I would want details.  I would want to know if my doctor’s recommendation is backed by expert opinion rather than multiple high-quality randomized controlled trials.  There’s nothing wrong with relying on expert opinion until we have objective scientific studies to better inform us, but omitting this detail falsely implies a high level of confidence in the benefits of the intervention.  Likewise, understanding the benefit of a test or medication on the quality or quantity of my life can impact my decision. For example, prior to undergoing a cancer screening test, I would want to know if the screening reduces all-cause mortality (meaning that I might live longer) or only cancer-specific mortality (meaning I’m not going to live longer, but I’m less likely to die from that cancer).  Additionally, I need to know the risk of harm from false positives, incidental findings, and overdiagnosis.  I can find this data in the literature myself, but most patients depend on their provider for this information, and probably most would find it valuable.  But these are difficult concepts—can they be translated into a language that most patients can understand?    

This is where healthcare providers can realize their value to patients.  Instead of quoting misleading statistics like sensitivity/specificity or relative risk, we can offer statistics such as absolute risk that are meaningful to patients.  For example, “screening low-dose CT reduces lung cancer death by 20%,” is better stated as “for every 1000 patients screened, 3 lung cancer deaths will be prevented, while 18 people will still die of lung cancer despite screening⁴.” If we can translate the complex into the understandable, thereby empowering the patient to make an informed decision that incorporates their values, we’ve provided an immensely valuable service.  We’ve built trust in the patient-provider relationship.  Shared decision-making also may improve outcomes and reduce healthcare inequalities⁵.

It is evident that shared decision-making is worth the effort.  Fortunately, decision support aids like those found at healthdecision.com are available to facilitate these discussions.  It also may be necessary to seek continuing medical education on the concepts of evidence-informed decision-making.  Someday, clinical practice guidelines may make this easier, but until then, the responsibility is on the provider.  Doing the right thing is often difficult, and this is no different.  Shared decision-making is problematic, but it’s the right thing to do.

Bobby Scott, MD is a practicing family physician, educator, and host of What’s The Proof?, a podcast that seeks to help family physicians and other clinicians incorporate the best available evidence into their everyday clinical decision-making.

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References:

1. US Preventive Services Task Force, Krist AH, Davidson KW, et al. Screening for Lung Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(10):962-970. doi:10.1001/jama.2021.1117
2. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society [published correction appears in J Am Coll Cardiol. 2014 Dec 2;64(21):2305-7]. J Am Coll Cardiol. 2014;64(21):e1-e76. doi:10.1016/j.jacc.2014.03.022
3. American Diabetes Association Professional Practice Committee; American Diabetes Association Professional Practice Committee:, Draznin B, et al. 6. Glycemic Targets: Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022;45(Supplement_1):S83-S96. doi:10.2337/dc22-S006
4. National Lung Screening Trial Research Team, Aberle DR, Adams AM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409. doi:10.1056/NEJMoa1102873
5. Durand MA, Carpenter L, Dolan H, et al. Do interventions designed to support shared decision-making reduce health inequalities? A systematic review and meta-analysis. PLoS One. 2014;9(4):e94670. Published 2014 Apr 15. doi:10.1371/journal.pone.0094670