• Enhance your patient’s understanding of the decision-making process
• Involve your patient in this process
• Increase your patient’s commitment to plans made

Shared decision-making

• Don’t just educate your patient about the nature and effectiveness of treatment options, also discover your patients perceptions of costs and barriers so that these can be addressed together
• Establish an atmosphere conducive to participation
• Encourage and help your patient to make their own decisions
  • Two-way exchange of information
    • Doctor: technical and medical information
    • Patient: ideas, concerns, expectations
• Elicit your patient’s informed suggestions and preferences; negotiate any disagreements
  • Both parties must reveal their treatment preferences and agree on a course to be taken

Exercise: Take a moment to think about the steps necessary in order to successfully undertake shared decision-making with your patient. Specifically think about what steps are need in order for the doctor to communicate the proposed disease management in the context of the patient’s illness perspective.

Essential Elements

• Together with your patient:
  • Define and explain the issue
  • Present options
  • Discuss pros/cons
  • Explore your patient’s values/preferences
  • Discuss your patient’s ability/self-efficacy
  • Discuss your recommendations
  • Check/clarify each other’s understanding
  • Make or explicitly defer decision
  • Arrange follow-up

Share your own thinking

• Your ideas, thought process, and dilemmas
• Allows your patient to begin to understand your rationale for decision-making
• Encourages your patient to contribute their views; may offer their preferences or further information to aid in your decision-making

‘There are two possibilities that might explain your symptoms. I think that an ulcer or gallstones are most likely. It’s not quite clear from the story you’re telling me or my examination which of these it is. I’m trying to decide on how to proceed, either we can treat it as an ulcer or move forward with testing to figure out the diagnosis for sure…’

Involve your patient

• Offer suggestions and choices rather than directives
  • ‘I think there are two choices available. Either we can start antibiotics now, or we can wait to see if this gets better on its own’
• Encourage your patient to contribute their ideas and suggestions
  • Signpost a clear interest in your patient’s comments
  • ‘You’ve probably given this some thought as well. Are those the choices as you see it? Which would you prefer?’
• Explore management options with your patient
  • Provide information regarding risks and benefits of each option (including no treatment)
  • ‘So to recap we have two options, either we can start the antibiotics right away, or we can wait and see how your illness progresses and treat with antibiotics if things don’t improve. Would it help with I ran through the pros and cons of these choices?’
• Risk communication
  • Attempt to present risks and benefits in an objective and unbiased manner
  • The most accessible way to present this information is by using natural frequencies rather than percentages
  • Patients differ in the way they understand complex information: consider using visual aids or decision tools to aid your patients
  • ‘If 100 people in your position decided to not have treatment, in 10 years 6 of those 100 people would have a heart attack or stroke. If those same 100 people took blood pressure medications for 10 year, 4 of them would have a heart attack or stroke.’

Exercise: Think of the different ways the same information can be presented in a biased manner. For example, 2% risk of death could be presented as 98% survival, with very different connotations.

Explore the possible management options

• Nature, risks, benefits, side-effects, etc.

 Ascertain the level of involvement that your patient wishes in decision-making

‘So, here are several things that we might try here. Each, as I’ve said, has its own set of pros and cons. Do you have any clear preference?’

 Negotiate a mutually acceptable plan

• Signpost your own position/preference or equipoise regarding further management
  • ‘In this particular instance, I personally would consider taking medication to reduce your blood pressure. I think given your very strong family history of heart disease and your other risk factors for heart disease that the benefits of taking the medication out-weigh the risks. What do you think?’
  • Overall, I think the position is finely balanced and I don’t have a strong feeling either way whether you should start the blood pressure medication yet. I think it comes down to the relative importance you place on the various things we’ve discussed’
• Determine your patient’s preferences
  • ‘What do you think overall? What would be your preference?’
• Negotiating differences
  • ‘What I’ve suggested as a medical professional makes sense to me, but if it isn’t right for you, we’ll need to think again. Tell me how you feel about what I’ve suggested.’ OR
  • ‘I have some reservations about taking the approach you’re suggesting. Can I explain them to you and then perhaps we can try to find a solution that works for both of us?’

Check with your patient

• Do they accept the proposed plan?
• Do they have any remaining concerns?

Silverman, J., Kurtz, S., & Draper, J. (2013). Skills for Communicating with Patients (Thrid Edit). London: Radcliffe Publishing.