What is 'Shared Decision-Making' in healthcare?

As Dr Alex Waddell explains, it is an interactive, two-way process where the clinician presents the patient with the risks and benefits of different treatment options. In the meantime, the clinician will also ask the patient for their insights into their preferences, goals and values. They work together and have a discussion about what they are going to do next for the patient's health and well-being.

Though this practice is not currently the 'norm' in western medicine, the benefits to implementing this process in medical decision-making is clear and backed up by evidence. These benefits include improved patient satisfaction, improved health outcomes, and reduced healthcare costs.

So, why has this not become common practice in modern medicine? What are the facilitators and barriers to Shared Decision-Making in healthcare and how can we support its uptake?

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Transcript:

Geoff

I'm talking to Dr Alex Waddell today about shared decision making. What exactly is shared decision making? 

Alex

So shared decision making in health care is really a process between clinicians and patients. It's an interactive two way process where a clinician will present the patient with the risks and benefits of different treatment options, and they ask the patient to tell them about their preferences and their goals and their values, and they work together to have an interactive discussion, maybe over one session or multiple sessions and decide together what they're going to do next.

Geoff

Is this current practice across Western medicine? 

Alex

No, it's not current practice across all of Western medicine. Certainly there are clinicians that do it extremely well and patients that advocate for themselves so that it happens in consultation with their own clinician, but it's not the norm. 

Geoff

So what are the barriers to shared decision making historically? 

Alex

Historically, medicine comes from a place of paternalism.  So that the clinician knows what's best for the patient and tells the patient or decides for the patient. And it's really a one way information exchange. So if I'm the clinician, I tell you what's best for you. We know now, though, that patients actually do better when they're involved in decisions about their care. They have better health care outcomes.  Their health care utilisation is lower and some report increased quality of life if they've been involved in decisions about their care. 

Geoff

What sort of interventions would you use to bring about this kind of behaviour change? 

Alex

So it's really key in shared decision making. It's not one size fits all interventions need to be really context dependent. It's really important to work with different stakeholders within the context that you're trying to implement shared decision making, to design something that suits them and their needs.  And within those stakeholders, you really need patients to be involved and you really need clinicians as well as health service administrators and decision makers. So that needs to be a whole range of people involved. And then you need to look at the barriers and facilitators for shared decision making within that context. And then you can use behavioural science to map out what might work and again, co-design with those people to come up with interventions that could work for the area.  So it's not just clinicians, it is patients as well having the confidence to be able to have that. 

Geoff

It's kind of a new relationship with their clinician in a way?

Alex

Yeah, absolutely. Patients need to be invited in to have those conversations and they need to be in a safe space in which they feel that they can do that.  A lot of the time patients feel that they are better able to have those conversations with a clinician that they trust. So if they have continuity of care, if they're seeing the same clinician over and over again, they're able to build those trusting relationships and to better engage in shared decision making. 

‍Geoff

And I would imagine that if clinicians are under pressure, they might feel it's a more efficient process to say "Here's the solution", type out the prescription and go, but this is a different relationship that you're looking for. 

Alex

Yeah, that's correct. Of course, it's really difficult for clinicians to have really busy case loads and they're trying to do a lot of things, a lot of different administrative tasks as well as care for their patients and get the right diagnosis for their patients.  It's actually been shown that you can avoid misdiagnosis, especially preference misdiagnosis, when you include patients in decisions about their care.

Geoff

Where does this work sit in terms of a behaviour change framework?

Alex

So the framework that we used in this PhD was the theoretical domains framework. It's a framework rather than a theory by itself. So it integrates a whole bunch of different theories into one framework and helps you to step through the process of either predicting behaviour or understanding behaviour and the different barriers and facilitators that influence behaviour. So the way that we did that did this was to identify through qualitative interviews, barriers and facilitators for a range of stakeholders using the theoretical domains framework.  Then we were able to map that to different behaviour, change techniques through the behaviour change wheel, and then to also map with the theory and techniques tool. From there, we went into a co-design phase. So we used a phase which is acceptability, practicability, effectiveness, side effects and cost effectiveness. And to ask a range of stakeholders what will work and what won't work in their own context.

But underlying that was the behaviour change techniques and the TDF. So it was both informed by the context and the needs of the stakeholders and also the theory that underlies behaviour change. 

‍Geoff

This is systemic change in a way. It's not just clinicians and patients. So can you talk to that a little bit more? 

Alex

Hospitals are now expected and required to prove that they're implementing shared decision making in practice.  With the national accreditation standards for hospitals in Victoria specifically, we also have the Partnering in Health care framework, which requires health services to implement shared decision making within a five year period. So there's really two policy levers that are being pushed to help health services to implement shared decision making. But as we found from the systematic review, there's not a lot of evidence for what works.

So hospitals are kind of left with this thing that we're supposed to be doing, but we're not sure of the evidence for how to do it best. And that's why we use co-design and behaviour change, because that enables us to use some theory to on to underline, to base what way, how we're trying to change behaviour, but more importantly, to really base it on the context and the needs of the people who work within the health care setting.  They're the ones that know best what will work for them and what won't work for them, 

Geoff

Did they generate any suggestions about how best to change this sort of behaviour? 

Alex

Yeah, they came up with three interventions. So the first intervention is changing electronic medical records. So that clinicians prompted to include patients in decisions about their care, but also so that patients have the opportunity before they see the clinician through the patient portal to be able to see that they will be having a conversation about shared decision making.

The second intervention is a multi faceted mass media campaign within the health service. So text message posters, email communications to try and persuade people that shared decision making is something that is expected and done at that health service. And the final one is to establish a series of clinical champions within shared decision making for that health service. So helping them through role play exercises and through behaviour change exercises.

So the other clinicians have got somebody that they can go to when they're trying to learn how to do shared decision making. Part of that is also for junior clinicians to be involved in role playing exercises within the Health Services simulation lab. So they practice with acting patients on how to do shared decision making conversation. And then they're also given a mechanism through which they can collect instances of shared decision making that they see from their senior colleagues.

Geoff

Is there an instance where it's not appropriate to initiate decision making? 

Alex

In really acute emergency situations in which the patient's not able to talk or there's not time to have those types of decisions. 

Geoff

And shared decision making has moved into maternal health in terms of women are much more empowered these days to to choose the type of personal care they want.

Alex

Yeah, women say that they want to be involved in decisions about their care and that they expected a lot of the people, a lot of the women, rather, that I spoke to cited the Australian Charter of Health Care Rights and said it is my right to be involved in decisions about my care. So in some parts of medicine it's already beginning to change.

You're talking about a wider clinical approach to shared decision making. My PhD focused on maternity care, in particular, but the previous research has focused on a wider range of clinical contexts, especially in primary and secondary care. Not so much tertiary care or hospital based care. 

Geoff.

Okay, thanks for your time.