A new paper from the National Institute for Health Care Reform discusses shared decision-making, a method of engaging patients and physicians jointly in making evidence-based, fully informed decisions on the patient’s care. (NIHCR Paper) Shared decision-making is particularly appropriate when there are multiple possible approaches to treating a particular illness or condition. The primary features of shared decision-making are providing easily understandable information to patients about each possible treatment, including the benefits, risks and costs. The provider should also elicit and understand the patient’s preferences about care. Studies have shown that shared decision-making is rarely used, that patients often feel that providers do not understand their values in regard to care and that their care does not reflect their preferences. Much of the time this results in care that is more invasive and costly than patients desire.
Barriers to more use of shared decision-making include the need for good decision aids in written or video form. Some organizations have begun to create these. Providers need to be trained to use the technique, particularly in regard to understanding patient values. And perhaps most importantly, providers need to be paid to take the time to engage with patients. Currently, most reimbursement does not explicitly compensate physicians for this time and may create incentives to do excessive testing and procedures. There are also malpractice fears that may need to be alleviated by legislation. Shared decision-making may be resisted by some patients, who just want to let the doctor decide, so patients may also need incentives to participate. And obviously many high-cost patients may have dementias or other problems that make participation difficult, so surrogate decision-makers may need to be engaged.
Lets all be honest, those who oppose all or components of shared decision-making usually do so for financial reasons. Drug, device and equipment companies fear the reduction in use of their products that might result from better informed patients realizing that those products often have limited efficacy and often have significant risks associated with their use. Providers fear loss of revenue from procedures and other services that patients tend to decline when they are more fully informed and when their preferences are understood. It is very hard to see any legitimate objection to incorporating this approach into any appropriate care inflection point and to paying providers for the time it takes to do it correctly. This would result in better care and more patient-centered care.