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Explore This IssueJune 2018
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Over the past several decades, the medical community has been moving toward a model of shared decision making. In addition to its ethical advantages, shared decision making potentially yields such benefits as improved medical adherence and better health outcomes. With the proliferation of treatment options and changes in the larger culture, shared decision making is even more important. Yet practical barriers leave many questions about how to best implement the practice.
For several decades, modern medicine has been moving away from a paternalistic model of medical care and toward patient-centered medicine, with the earliest mention of shared decision making dating from 1982.1 An influential article on clinical practice guidelines argued that interventions should be considered standard only if there is almost unanimous agreement among patients about the desired outcomes.2
For the majority of clinical decisions, no single intervention meets these criteria. In most cases, more than one reasonable option is available, with each option having its own strengths and possible side effects. Thus, patient preferences and values must be considered in determining the optimal treatment strategy.3
Both European League Against Rheumatism (EULAR) and ACR guidelines recommend shared decision making when choosing treatment options, incorporating patient values and preferences in the final decision.4,5
Sonali P. Desai, MD, MPH, is an associate physician in rheumatology at Brigham and Women’s Hospital and an assistant professor of medicine at Harvard Medical School in Boston, Mass. She believes a variety of factors has propelled the move toward shared decision making. Among these are greater access of medical records to patients, increased availability of general medical information (via the Internet) and direct to consumer marketing. She notes, for example, that the number of medications available to treat rheumatoid arthritis has grown quite substantially over the past decade or more.
“When you have more options, there is more of a conversation that you need to have regarding what you should do next,” Dr. Desai says.
A variety of factors has helped propel the move toward shared decision making. Among these are greater access of medical records to patients, increased availability of general medical information (via the Internet) & direct-to-consumer marketing.
Defining Shared Decision Making
In the older, paternalistic model of medicine, physicians made treatment decisions with little patient input. In the shared decision-making model, patients and physicians work in tandem to come to treatment decisions. Clinicians come with their clinical acumen and expertise, and patients come with their expert knowledge of their own personal experiences, as well as their own preferences, values and lifestyle goals. The idea is to support patients in the decision-making process—not to make them feel abandoned and alone with the sole responsibility for their decisions. At its heart, the goals of shared decision making derive from a belief that individual self-determination is desirable whenever possible and that clinicians should support patients in this.6