Shared decision making is challenging to define in a precise way. However, generally speaking, a process of shared decision making simply means that patients’ preferences and choices must be incorporated as physicians and patients make joint decisions on their medical care.
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Explore This IssueJune 2018
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Dr. Desai notes, “In some cases the next step is pretty clear—you don’t need to have a huge conversation.” But in other cases, important questions can and should be asked. “Would you rather come to the hospital for an infusion every month, or is it better for you and your lifestyle to give yourself an injection? Or is the potential risk of this side effect vs. the benefit offered by this treatment more important to you? Sometimes people want to continue to drink two glasses of alcohol every night, and then methotrexate may not be an option.”
Robert H. Shmerling, MD, is associate physician and clinical chief of rheumatology at Beth Israel Deaconess Medical Center and an associate professor of medicine at Harvard Medical School in Boston. He is a rheumatology consultant for a grant sponsored by the Institute for Healthcare Improvement studying shared medical decision making in rheumatology. He notes, “My own approach is that I want to give patients the information that they need to make a good decision, but it is their decision. I embrace the idea that if the patient is going to take a risk by taking a medication—and of course, all medications have risk—then they need to know what they are getting into and be enthusiastic or at least supportive of the plan that we come up with.”
Dr. Desai says, “I always tell people up front: ‘We want to get you better, but we need to come up with a treatment plan that you feel comfortable with and you are going to be able to take, because I could prescribe for you one of many things. But what’s the best option for you given your overall health and preferences?’ I try to get them involved in the conversation.”
Dr. Shmerling adds, “If I feel like the patient has an understanding of why I’m recommending what I’m recommending, and they decide they like something different or they don’t want to do that, then I have to accept it. It is a completely different model, one in which the patient is the focus rather than the doctor telling them what to do. I often say to my patients, it’s like being a coach with players: You can recommend a certain way of doing things, but ultimately they’ve got to buy into this system and actually do it.”
Benefits: Increased Adherence
One of the key benefits to a shared decision-making model is increased medical adherence. Approximately 50% of people with chronic medical conditions do not take their medications as prescribed, and estimates of medication adherence among rheumatoid arthritis patients range from 30% to 80%.7,8 This nonadherence has a devastating impact on health outcomes, severely impairing the effectiveness of treatment.8 It has increasingly become recognized that patient preferences play an important role in adherence to prescribed therapies.9 Patients may have a variety of preferences influencing the best treatment option for them, including mode and frequency of administration, specific side effects, potential benefits and cost.