Shared Decision-Making

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Definition

Shared decision-making is a collaborative process between you and your doctor that identifies health decisions with no clear answer and tailors the best decision by incorporating your values and preferences.

About

The Strength of Evidence

Decisions about your health are primarily guided by medical science; consequently, one needs to understand how science works to understand how medical decisions work. Science is a method of testing out our ideas with a series of better and better tests. The better the test, the stronger the evidence the idea works. It is a decades-long arduous process which never reaches complete certainty - only degrees of certainty - based on the strength of the evidence.

Medical decisions can be split into two main types based on the strength of evidence:

Preference-Insensitive Decisions

These decisions are backed by very strong evidence. So strong, that preferences of the patient take a back seat. For instance, treating an open fracture (bone sticking out of the skin) with surgery, or treating very high blood pressure unresponsive to lifestyle modification with medications. These types of decisions represent only a minority - less than 10% - of medical decisions.

Preference-Sensitive Decisions

The other 90% or more of medical decisions are based on less evidence: the evidence is conflicting, the evidence is weak, the evidence is absent, or the treatment has almost as many harms as benefits. Examples include: treating high cholesterol with a statin in a person with low cardiac risk, poorly studied peptides, a new fad diet that claims to make you live longer.

This simple dichotomy - preference-sensitive vs preference-insensitive decisions - is an extremely powerful tool for a patient. For decisions backed by very strong evidence, very little deliberation is required. You MUST get surgery for an open fracture. The choice is straightforward, and your preferences bear little relevance.

For decisions based on weaker evidence, far more deliberation is required. Bringing your personal preferences to the table is extremely helpful. For example, we certainly don't have strong evidence the 'carnivore diet' will make you live longer, so don't sweat it if you don't like meat.

David Hume's simple maxim - a wise person proportions their beliefs to the strength of evidence - perfectly reflects this principle. In health, a wise person should proportion their decisions to the strength of evidence.

About

The Culture of Certainty

Unfortunately, there is a major disconnect between the uncertainty of medical science and the practice of medicine. Healthcare professional don't incorporate patient preferences for the majority of decisions. We practice as if they're based on strong evidence. We practice with certainty.

Why do we behave this way? The problem runs deeps and begins in training. We have a 'culture of certainty'. It is due to many factors:

'Certainty' Beginning in Training

Most of the practice of medicine relies on pattern recognition. To help us learn we are presented with the "textbook" cases. Cases with nuance are specifically avoided. Student that answer, "I don't know", or "it's complicated", are chastised. This leads to a 'black or white' view of medical science.

To Reduce Work Load and Cognitive Load

Explaining to a patient the nuance of a medical intervention, and how their preferences fit in, is not only very time-consuming, but requires significant mental effort. These resources are already strained in most healthcare professionals. It is cognitively "cheaper" for both the doctor and the patient to view decisions in simple preference-insensitive terms.

Medical Paternalism

Many healthcare professionals don't want to share control with patients. They see patients as childlike and weak, uninformed and emotional, and benefit more from placebo effects than knowing the truth. This "doctor knows best" attitude is pervasive. It's called, medical paternalism.

False Certainty From Bias and Conflicts of Interest

All healthcare professionals harbor bias and conflict of interest to some degree. They are philosophically and financially motivated to see health through the lens of their specialty, and reside in information echo-chambers impervious to refutation. They see THEIR tools as better and safer than they really are. All of which creates false certainty.

Patients Seek Out Certainty

Patients seek out certainty; especially when it comes to our health. Imagine if your surgeon said, "Maybe you should get the surgery, I don't know", or if your functional medicine doctor said, "These peptides are experimental, we really don't know if they are safe". Studies show we use confidence as a marker of competence. We are hard-wired to think like this. Healthcare professionals learn this intuitively, and adapt.

Shared decision-making is designed to help patients make better decisions by directly confront the 'culture of certainty'. Let's learn more about shared decision-making...

About

Shared Decision-Making

Shared decision-making is a collaborative process between you and your doctor that identifies health decisions with no clear answer and tailors the best decision by incorporating your values and preferences. It leverages two experts in the room: your doctor - an expert in medical science, and you - an expert in you and your preferences. Only with with this exchange can the best decisions be arrived at.

Here are the steps of shared decision-making:

Step 1 - Find a Medical Expert

To start the process, you must find an expert with the necessary time and skills to devote to the process, and willing to share control. Unfortunately, these prerequisites are rarely met, and may be a good application for artificial intelligence. But, learn how to prompt properly and beware of AI hallucinations and sycophancy.

Step 2 - Specify: Patient, Intervention, and Outcome

Medical decisions can't be made in a vacuum. Details are extremely important. Patient details (like your age, medical history, and risk factors), intervention details (like dosage, frequency, and route), and desired outcome (like longevity, or more energy). use AI to help you gather information, "You are an expert in evidence-based medicine, I am considering intervention X, what information do you need to help me make that decision?" One must specify the patient, "A healthy 30 year old male" or "A 60 year old female with prior heart attack", the intervention, "A statin" or "HIIT training", and the outcome, "Prevent heart attacks"or "Live longer". The more specific the claim, the better. "Are statins good for you?" is unanswerable.

Step 3 - Identify Preference-Sensitive Decisions

Preference-sensitive decisions are decisions NOT backed by strong evidence. They represent the majority of decisions in healthcare. With AI, use the following prompt for example: "You are an expert in evidence-based medicine, is there strong evidence that a 60 year old female with a prior heart attack should take statins to prevent heart attacks?"

Step 4 - Understand the Benefits

Once a difficult decision is identified, your doctor must try to present you with the benefits of the treatment in an understandable way. Shared decision-making employs various 'decision aids' for this purpose. Decision aids try to display the information visually. As an example, Mayo Clinic has an excellent decision aid to educate patients on the benefits of statins. Let's plug in the numbers for a 55 year old healthy male with a cholesterol of 250 (normal is below 200). The program produces the grids below:

Step 4 - Understand harms

Unfortunately, with many interventions, the data concerning harms is not as robust as the data concerning benefits. Harms are difficult to detect especially if you are not specifically looking for them. Treatments based on rat experiment or supplements, for example, will often advertise themself as "no side effects". This is a classic error in logic and science, "Absense of evidence is not evidence of absense.

Step 5 - Learn alternatives

Furthermore, harms go beyond the direct 'side effects' of an intervention, they includes opportunity costs. We only have a certain bandwidth of attention and resources to direct to our heatlh. This intervention may require tremendous time and efforts, which either displaces other health interventions, with better benefits and less harms, or you could have been reading a book and enjoying the life you have left. For example, Your medical problem may have many treatment options. Your doctor must be able to give you a comprehensive analysis of all these alternatives. With respect to elevated cholesterol, there are many treatment alternatives to statins. These include: other prescription medications, supplements, herbal products, dietary modification, exercise, and weight loss, to name a few. Each of these options has its own benefits, harms, and supporting evidence to be reviewed.

Step 6 - Incorporate your values and preferences

Just like a financial advisor needs to know, "how lavish is your lifestyle", "when do you plan to retire", "what is your tolerance for risk", before they can determine the best strategy for you, you need to work with your doctor to determine the best medical strategy for you

Once you have an understanding of the benefits, harms, and alternative options for a treatment, the next step is to incorporate your values and preferences. It appears that a healthy person with a high cholesterol does not benefit that much from a statin. But, some people are more risk averse than others. This is where your personal values come in. How much do you value a 1% reduction in the risk of a heart attack? Some find a 1% reduction significant, while others find it negligible. What about the inconvenience of taking a medication every day for 10 years? Would you prefer not to do this? Maybe you already take supplements, and adding one more pill won't bother you. The potential for harms with statins seems small, but not negligible. Would you, instead, prefer to try one of the alternatives - such as diet and exercise? Can you maintain diet and exercise, or would you rather take a pill? What is your preference?

What outcomes matter to them the most?

In the absence of strong evidence of benefit from statins, incorporating these personal values and preferences into a difficult decision, ensures we arrive at the best decision for you.

Step 7 - Repeat the above process

Ideally, the process of shared decision making is iterative - meaning - it is repeated several times over the course of months and years until it is perfected. Each time, the scientific evidence improves in quality, your understanding of your values and preferences improves in quality, and the collaborative dialogue between you and your doctor improves in quality. Thus, the decisions improve in quality.

For more information on shared decision making, feel free to explore some of the medical centers spearheading this approach, like Dartmouth and Mayo Clinic .

About

Engineering Shared Decision-Making Into My Practice

Shared decision making can be very rewarding for both patients and doctors; however, it requires time. This makes Concierge Medicine the optimal practice model for shared decision making. My practice is small, freeing me up to collaborate with my patients and help personalize difficult decisions.

However, shared decision making takes more than time. Doctors must be willing to share control of decisions with patients. This takes experience and empathy. The patients in my concierge practice are intelligent and independent thinkers. Some have travelled the world and bring tremendous experience to the table. After working with them, learning from them, and listening to their needs for 25 years, sharing control comes naturally to me.

On the other hand, despite the intelligence and independence of patients, patients can still be vulnerable. Patients know less than specialists. They often fall prey to specialists with bias and conflicts of interest. They are sold tests for diagnoses they don’t have, and treatments for diseases they don't need. To protect patients for this I have designed my practice to empower them. This is accomplished by: ensuring I am free from bias and conflict of interest, teaching my patients how to apply critical thinking to medical decisions, and providing them with a large pool of alternative options with my comprehensive approach . My goal is to level the information player field between patient and specialist. Once empowered, I can help patients apply their personal values and preference to difficult decisions, ensuring we make the decision that is best for them.

Fortunately, patients can be empowered and learn how to evaluate any claim objectively for themselves. Other resources include your primary care doctor and AI platforms.