Some more thoughts on shared decision making

Nice JAMA Viewpoint on shared decision making:

The growing emphasis on patient-centered care is increasing the demand on physicians’ time and effort to more fully engage patients and their families in treatment decision making. Thus, it is important to understand the potential effects of shared decision making (SDM) with patients on the outcomes of clinical encounters. Shared decision making is being strongly promoted for several reasons. First, it is the ethical responsibility of clinicians to facilitate patient involvement in treatment decision making because patients and their families are ultimately subjected to the outcomes of these decisions. Second, there is evidence that more engaged patients are more informed, more likely to fully deliberate about the risks and benefits between different treatment options, and ultimately more satisfied with the clinical encounter. The objectives of SDM are to fully inform patients and their families about treatment options, including the trade-offs between risk and benefits, and to incorporate patient values and preferences into treatment decisions.

I have no argument with the first point. Informing patients fully is just right, full stop.I don’t doubt the second, either. Makes total sense that informed patients are more satisfied with their decisions. It’s the next thing I have an issue with:

More recently, SDM has also been promoted as a strategy to reduce overtreatment and costs, a rationale grounded in the belief that better-informed patients may be less likely to choose a treatment strategy more extensive than that recommended by their clinicians. The increasing expectations about the role of SDM in clinical and health policy warrant closer scrutiny of the evidence.

There’s really no evidence for this. I don’t know where people came up with the belief that “better informed” equals “cheaper”. That would assume that the system leans towards efficiency, but patients are pushing us – ignorantly – towards spending more. Does anyone believe that to be the case? I’ve been arguing for some time that patient knowledge isn’t the biggest problem in the system.

This is part of our ongoing inability to separate out access, cost, and quality. Some interventions are designed to increase access. Some are designed to reduce spending. Shared decision making is about improving quality. I think there’s a growing amount of evidence that it might work, specifically when we consider patient-centered outcomes. But just because it improves quality doesn’t mean that it will reduce spending. It might do just the opposite.

Sometimes good things cost money.


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