papers – care that fits

Technical versus Humanistic Shared Decision Making revisited: Evaluating its occurrence

Submitted by Marleen Kunneman & Victor Montori

In an earlier post, we reflected on technically correct and humanistic shared decision making (SDM). In our view, it is unclear “whether having a technically correct structure of the SDM process improves the likelihood that the care decisions made will contribute to improve the patient situation.” We called to look beyond what is technically correct, to uncover humanistic SDM and caring conversations.

We recently published a systematic literature review in which we assessed the extent to which evaluations of SDM assess the extent and quality of humanistic communication, such as respect, compassion, and empathy. We looked for studies evaluating SDM in actual clinical decisions using validated SDM measures. We found 154 studies, of which only 14 (9%) made at least one statement on humanistic communication. This happened in framing the study (N=2), measuring impact (e.g., empathy, respect, interpersonal skills; N=9), as patients’ or clinicians’ accounts of SDM (N=2), in interpreting the study results (N=3), and in discussing implications of the study findings (N=3).

In addition, we looked whether the validated SDM measures used contained items on humanistic communication. The eleven SDM measures used contained a total of 192 items. Of these, only 7 (3.6%) assessed aspects of humanistic communication.

Our review shows that assessments of the quality of SDM focus narrowly on SDM technique and rarely assess humanistic aspects of the patient-clinician conversation. We conclude that considering SDM as merely a technique may reduce SDM’s patient-centeredness and undermine its contribution to patient care.

In evaluating technical SDM, we have measured with our eyes and our ears. Perhaps the fox from “The Little Prince” was on the right track when he noted: “It is only with the heart that one can see rightly; what is essential is invisible to the eye.”

The full paper was published in Patient Education and Counseling and can be found here.

This study was part of the Fostering Fit by Recognizing Opportunity STudy (FROST) program, and has been made possible by a Mapping the Landscape, Journeying Together grant from the Arnold P. Gold Foundation Research Institute.

Papers and presentations, shared decision making

New treatment guidelines consider patient characteristics

A recent article in the Wall Street Journal, Health & Wellness magazine, New Strategies for Treating Diabetes, discusses new guidelines for treatment of Type 2 diabetes which were published in June. The new guidelines suggest patient preferences and characteristics such as age and general health be considered by doctors when treating patients with Type 2 diabetes. The Shared Decision Making National Resource Center has promoted this consideration of patient preferences and individualized treatment plans. Patient decision aids, which are developed through the Center, give voice to the patient, as Dr. Montori points out as important in the article.

Papers and presentations

What patients want

An interesting article from KevinMD.com was shared with us: “How much guidance do patients want with their medical decisions?”

Victor Montori, MD, comments:

While the surveys consistently show that not all patients would like to make the final decision about treatments, these surveys have two major flaws: 1) The majority of patients interview have never experienced a high-quality shared decision making interaction. 2) The decisions asked are infrequently described to the respondents of these surveys as being those in which there is no right or wrong choice.

Patients do not like to be asked to make a decision for which there is a technically correct choice. And who knows the right answer? The doctor. The decisions that are most amenable to shared decision making are nontechnical ones in which the options have trade offs that only the patient can seriously evaluate, with the help of a caring clinician. This last point is well illustrated in this piece.

We agree with the commentary writer that the context of primary care and healthcare in general is not conducive to shared decision making, and this is why this will require a patient revolution.