The supplement to February’s Medical Care Research and Review is all about shared decision making (SDM), of which I’m a big fan. Clarence Braddock’s paper is one of several in the issue on the value and use of SDM in low-information settings (poor quality or low quantity of evidence). In addition to learning that the SDM concept has its origins in the President’s Commission for the Study of Ethical Problems in Medicine (1982, PDF), I thought this passage worth sharing:
Many authors have chronicled the dysfunctional manner in which physicians and patients grapple with uncertainty (Bursztajn, Feinbloom, Hamm, & Brodsky, 1990; Fox, 1980). As clinical questions arise at the limits of medical knowledge, uncertainty increases and the clinician’s angst along with it (Evans & Trotter, 2009). Patients often assume that there is certainty in clinical medicine, an assumption which for many reasons many clinicians are loathe to dash (Gerrity, White, DeVellis, & Dittus, 1995). In part, physicians are often reluctant to acknowledge uncertainty for fear that doing so may undermine the confidence that the patient has in them (Johnson, Levenkron, Suchman, & Manchester, 1988). Their socialization into the medical culture has taught them that patients will not trust a physician who is uncertain or indecisive. Many physicians further worry that uncertainty will only increase the patient’s anxiety, potentially contributing to reluctance to pursue what the physician feels is the “right” treatment. As a result, physicians will feign certitude to reassure the patient (Fox, 1980).
This is not at all surprising, but the documentation of it with references may be of use. If you can get your hands on it, Braddock’s paper is worth reading in full, as are others in the supplement, about which I may blog more later. More President’s Commission documents via Wikipedia.