Why & How to Pursue Shared Decision Making with Your Patients

Dr. Cozad

Melanie J. Cozad, PhD, is an assistant professor in health services policy and management at the Arnold School of Public Health at the University of South Carolina in Columbia. “Treatments offer different trade-offs between symptoms and side effects, but also possibly impede the goals individuals have for their lifestyle. If we end up with a treatment that is not compatible with where you want to go in your life, then you are probably not going to adhere to it.”

Dr. Desai agrees, but she also notes patients may have other reasons not to adhere that cannot always be addressed by shared decision making. She cites the example of patients prescribed etanercept or adalimumab who need to give themselves a shot every week or every other week. Some patients get so anxious about the shot they find it even worse than the condition being treated. “Sometimes you find that out too late,” she says. “It’s better to have that conversation up front and be open about it.”

Evidence from many randomized trials supports the idea that shared decision making fosters a number of other important outcomes. These include increased confidence in decisions by patients and increased patient knowledge. Some evidence suggests that patients involved in shared decision making are also more likely to opt for conservative treatment options where appropriate.⁶

Ultimately, greater use of shared decision making could help reduce overall healthcare costs by increasing medical adherence and helping patients avoid treatments they don’t want.¹⁰

Diverse Patient Perspectives

Patients differ in their interest in and willingness to participate in shared decision making. Dr. Shmerling notes, “Some patients are very much in the older model of paternalistic doctors telling patients what to do. And they say, ‘I appreciate you offering all this information to me, but you just tell me what to do, and I’ll do it.’ That tends to be older patients.”

He contrasts this with another group of patients. “There are others who arrive very interested in being part of the decision making, and they already have some ideas about what they want to do to manage their arthritis, from their own research, from their friends or family.”

Dr. Desai concurs: “Some patients will be fine with the more paternalistic approach. Also, because of the complexity and number of choices, even if they were given choices, they still may not know which one makes the most sense. They are looking for you to guide them in that process.” She notes that some people come from negative experiences with their healthcare in general. “Either they may not feel empowered to really speak up to share their preferences or what they really think, or that may not be part of their personality.”