There are many decisions in medicine that are straightforward and do not require much deliberation. For instance, an open fracture (with the bone sticking out of skin) must be immediately repaired with surgery. A persistent high blood pressure of 240/120 should be treated with medications.
At the same time, there are many decisions that are not so straightforward. Difficult decisions where the evidence is conflicting, the evidence is lacking, or the treatment has almost as many harms as benefits. In fact, most decision in medicine are difficult. It’s estimated that only 10% of medical decisions are backed by strong evidence. Examples of difficult decisions include: treating high cholesterol in a healthy middle-aged person, testosterone replacement for aging males, and chemotherapy for metastatic pancreatic cancer. These are difficult decisions with no one best answer. This is where shared decision making is useful.
Shared decision making
Shared decision making acknowledges there is no one best answer for difficult decisions. Instead, the goal of shared decision making is to make decisions that work best for you. It is a personalized approach that incorporates your values and preferences into the decision. This requires an open collaboration between you and your doctor. After all, there are two experts in the room. Your doctor caries expert knowledge of medicine, and you carry expert knowledge of you.
Shared decisions making leverages your doctors expert knowledge of medicine with your expert knowledge of you - your values, and your preferences.
Steps in shared decision making
Let me take you through the steps involved with shared decision making. As an example, I will apply shared decision making to decide whether we should treat high cholesterol in a healthy middle-aged person. Should we use a statin drug or not?
Step 1 - Share control
The prerequisite of shared decision making is working with a physician that is willing to share control. In medical school, physicians begin their training in acute care settings and hospitals. In these kinds of extreme and unfamiliar circumstances, patients often entrust decision making to their physicians. This engenders the traditional paternalistic mindset of medicine - the physician knows best - the physician is in control. However, when physicians get into the real world, they begin working in outpatient settings dealing with preventive medicine and chronic conditions. Decisions are less straightforward and patients want to get involved. The mature physician learns that the best decisions are made in collaboration with their patients. The mature physician shares control with their patients.
Step 2 - Recognize difficult decisions
The next step in shared decision making is to recognize which decisions are straightforward and which decisions are difficult. This step is crucial and requires objectivity. Your doctor should be free from bias and conflict of interest. The issue of cholesterol and statins, for instance, is filled with extreme opinions. Some specialists believe high cholesterol is not a problem, it's all part of a Big Pharma conspiracy, and statins are dangerous. For them, treating high cholesterol is not a difficult decision - it should never be treated. Other specialists believe the opposite; cholesterol is the only problem. For them, treating high cholesterol is not a difficult decision - everyone, at every age, should take a statin. An impartial doctor, however, uses critical thinking to objectively assess the entirety of the evidence, and the quality of the evidence. The truth likely lies somewhere between these two extreme beliefs. High risk individuals can benefit greatly from cholesterol reduction with statins. However, low risk patients don't benefit as much, and statins have the potential for side effects. Consequently, it is a difficult decision whether a low risk individual, like a healthy middle-aged person, should take a statin to lower their cholesterol.
Step 3 - Understand 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 260 (normal is below 200). The program produces the grids below:
Each grid contains one 100 dots representing 100 patients. The 100 patients on the left grid are not treated with a statin, and the 100 patients on the right grid are treated with a statin. After 10 years, 4 (orange dots) patients on the left (not treated with statins) will have a heart attack, and 3 (orange dots) patients on the right (treated with statins) will have a heart attack. This visually demonstrates two points: a healthy 55 year old male with high cholesterol only has a 4% chance of having a heart attack over the next 10 years; and taking a statin will reduce this risk by 1%. Thus, the benefits of a statin in this patient are not great
Step 4 - Understand harms
Unfortunately, the data concerning the harms of statins is incomplete, conflicting and difficult to quantify. Although generally safe, harms may include: muscle aches, memory loss, diabetes, and liver inflammation. Most harms are reversible with discontinuation.
Step 5 - Learn alternatives
Your medical problems may have many treatment options. Your doctor must be able to communicate 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
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?
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.
Concierge Medicine and shared decision making
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.
For more information on shared decision making, feel free to explore some of the medical centers spearheading this approach, like Mayo Clinic and Dartmouth Medical Center.