Informed and shared decision-making: the crux of patient-centred care

Thirty-five years ago, when I was a medical student, we were taught to be paternalistic. We were trained to withhold information from patients, especially painful information about a potentially terminal illness; we were also instructed to take charge of interviews and to avoid getting “sidetracked” by patients' “irrelevant” concerns. The handbook that my university developed to teach the clinical method referred to the interview as “the interrogation.” Patients who did not comply with “doctor's orders” were called defaulters, untrustworthy, unreliable or faithless.¹

One of the biggest challenges for clinicians is finding common ground with patients about management. In this issue (page 434),² William Godolphin and colleagues describe an important study of informed and shared decision-making (ISDM). They surveyed 285 family practice preceptors of medical students to find out how common and challenging to ISDM were a group of scenarios. Conflict resolution (dealing with a patient who wants a test, prescription or referral that the physician does not think is appropriate or necessary) was the most common and most challenging scenario. I suspect that there are several reasons for this. A discussion of a patient's options and the pros and cons of each can be quite time-consuming. For example, I often find that it takes up to 3 office visits to discuss adequately the pros and cons of hormone replacement therapy. In addition, reading and reviewing material brought in by the patient may place extra demands on the physician's time. Some physicians may feel that their authority is being challenged. Others may fear that they may be sued if they agree to a treatment suggested by the patient that results in a poor outcome. Physicians want their patients to receive treatment that is most likely to be beneficial rather than an alternative, poorly studied treatment that the patient may prefer. Finally, physicians may feel that they do not have the necessary skills to confront disagreement in a constructive manner.

It is relatively easy to explore the patient's feelings and ideas, the effects of the disease on function and the patient's expectations (FIFE for short) — these can simply be added to the functional inquiry without changing the primary focus on disease. I worry, when students tell me that they “FIFEd” a patient, that they have not understood how to be patient-centred. If physicians are truly to connect with patients as partners in care, they must change their mindset and develop skills to involve patients in meaningful ways. Some critics of this approach argue that it is an abdication of their duty as physicians to hand over clinical management to patients, because physicians have an obligation to prescribe the treatment for which there is the best evidence for benefit. They indicate that it has become hard enough for physicians to determine best evidence, and to expect patients to participate in this decision in a consequential way is folly. But these critics misunderstand the mandate to involve the patient: physicians still have an obligation to contribute their expertise to the discussion and to involve patients in such a way that patients can use that expertise in making their own decisions about care. Patients expect to have significant involvement in medical decisions about their care, and there is a growing body of research about patient involvement showing that patients (as well as physicians) can expect improved outcomes.^3,4,5 In a study of the impact of patient-centred care on outcomes, Stewart and colleagues⁶ found that patients' perceptions of having received patient-centred care were associated with better recovery from their discomfort and concern, better emotional health 2 months later and a reduction of about 50% in diagnostic tests and referrals. The most important association with good outcomes was the patient's perception that the physician and the patient had found common ground; it was not enough simply to explore the patient's experience of illness.

Often, our approach to involving the patient, although well-intentioned, is flawed by a failure to accept the patient as an equal partner. One author⁷ referred to this as a meeting between experts, that is, physicians are experts in disease and patients are experts in their own experience of disease and in their preferences. The usual approach to finding common ground is still for the physician to outline a single set of recommendations, sometimes including a list of potential risks and side effects, following which the patient is invited to agree. If the patient does not agree, then the physician will go over the recommendations again, stressing the importance of each, asking if the patient has any questions and addressing any concerns. But it is uncommon to explore the patient's wishes for treatment. In a study of primary care physicians and surgeons, Braddock and colleagues⁸ reviewed audiotapes of informed decision-making and found that discussion of alternatives occurred in 5.5%–29.5% of interactions, of pros and cons in 2.3%–26.3% and of uncertainties associated with the decision in 1.1%%–16.6%. Physicians rarely explored whether patients understood the decision (0.9%–6.9%).

This paper by Godolphin and colleagues reminds us about our responsibility to engage our patients in the complex process of investigation and treatment planning; it points out some of the educational challenges we face, if we are to learn and teach the skills to succeed in this task. We can begin by recognizing the value of involving the patient as a partner and asking “What do you think?” more often. When the patient retorts, “You're the doctor,” the physician should respond with a comment such as, “Yes, and I will provide you with information and my expert opinion, but I really do want to include your thoughts and wishes in our planning together.” When you and your patient disagree about management, be sure to listen carefully to the patient's ideas and paraphrase them so that the patient knows that you understand his or her point of view. Then, express your concerns and engage in a discussion that seeks to find common ground. It is not always easy, but it is often interesting and rewarding.