When is the shared decision-making model appropriate?

It’s as if Kenny Lin* read my mind about the PSA test.

The answer is that primary care physicians have already been trying this [shared decision-making] approach for many years, and it does not work. Numerous studies have shown that no matter how much information men are given in any format, the vast majority still choose to receive the [PSA] test, and most of them end up worse off because of that decision. In fact, as a new study concludes in the Archives of Internal Medicine, once prostate cancer is diagnosed via PSA testing, the men most likely to receive aggressive (“curative”) treatments are those who are least likely to need it – men who would have been better off not getting the test in the first place.

Lin is a physician and he comes to a very strong conclusion that shared decision-making for the PSA test doesn’t work and should be abandoned, that physicians should advise against the test. He seems to know what “better off” means for patients.

I am not a physician and I am a little less confident (but not much less) than Lin that I can know what makes patients “better off” when it comes to the PSA test. Maybe I shouldn’t be so timid, but it’s my nature. Nevertheless, my main objective is to push back on the idea of shared decision-making as a concept that should be universally applied. I am willing to believe there are some tests, procedures, or medical services that the patient really shouldn’t have much say in. These could be things that are demonstrably overwhelmingly harmful and we just should not do them. There’s no point in educating patients about things so they can possibly choose a dangerous path. (The PSA test may not quite fit this description, but it might be close. We should not let patients hem and haw about whether they should undergo bloodletting though. There, I’m confident.)

Or there may be therapies that are, essentially, unique. If you arrive at the hospital with a hip fracture and want treatment, your hip will be reconstructed. There’s not a lot of wiggle room. If you have colon cancer and want treatment you’ll get a colectomy. Again, not many choices there. (Both examples are from Jack Wennberg’s book Tracking Medicine, which I am enjoying.)

Bottom line: Shared-decision making is not the only appropriate style of care delivery. It may be suitable for some care and not for others. That’s something worth discussing and I’m glad Lin raised the issue.

* I’m inferring Kenny Lin is his name. All I can find is his blog handle which is kennylin. Why do some blogs not have clear by-lines?


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