Shared Decision Making in Medicine

I was reading this ‘viewpoint’ in JAMA; an interesting read. I try to practice shared decision making as much as possible, perhaps more than what my patients would like.

However, I do feel that there is lack of data supporting shared decision making or ‘informed decision making’. I would perhaps define ‘informed decision making’ as decision making process in which patients are informed of their options and then given a recommendation by their treating physicians. Of course, patients have a right to say no to the recommended option, give reasons for refusing the recommended option, and then give their preferred option to the physicians.

Having said that, I am unaware of good data supporting any decision making strategy. There are, of course, tons of arguments supporting why shared decision making is good. But when, in medicine, we started depending on arguments without trying to develop evidence?

To develop evidence, first we have to define what is it that we want to achieve (an outcome). Some may argue that ‘shared decision making’ is in itself an outcome. I am not sure how this can be an outcome of choice. Perhaps a better outcome could be one that is patient-focused, such as mortality, morbidity, readmissions, quality of life etc. Things that matter are more meaningful. Or outcome that is physician-focused: such as number of law-suits by patients (or on behalf of patients). But there need to be reasonable outcome(s).

Then, we need to examine how shared-decision making affects those outcomes. My worry is that we are adding ‘must-do’ things in our workflow without determining their efficacy.

One way I look at the seriousness, or lack of it, by the proponents of a given ‘thought’ or ‘idea’ is their lack of desire to investigate their proposed remedy using scientific methods. We don’t accept a medicine, procedure, or treatment without strong evidence. Why we should accept other things using a lesser proof of evidence (unless we think it is not as important)?

One area where we find such a lack of seriousness in developing evidence is medical education itself. Even when we occasionally study a medical education intervention correctly, we find that our thinking was flawed. While we may claim that we understand the complexity of human behavior, we are often wrong. I doubt that we are right when it comes to shared decision making. When properly studied, I doubt we will find any effect on any important outcome.