Power imbalance prevents shared decision making

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This article highlights that whilst large scale implementation programmes in the UK have delivered valuable lessons on how best to embed shared decision making, adoption of shared decision making into routine clinical settings has been slow. 

The article summarises findings from a recent systematic review of patients’ perceptions, which found that many patients currently feel they can't participate in shared decision making. Power imbalances in the clinical encounter are a key barrier even if patients have the required knowledge, and patients need to know that their input is valued and won't damage their care. The attitudes of both patients and clinicians need to change to enable shared decision making. This paper highlights the main findings and discusses how to prepare patients for shared decision making.

The authors found even when patients are well educated and well informed, many still find it difficult to use this knowledge to participate meaningfully in decisions about their healthcare. The 44 studies in the review of patient barriers suggest that many patients currently feel that they can't participate in shared decision making rather than that they don't want to, as many clinicians believe.  Unsurprisingly, having information needs met in an appropriate way was a key facilitator for many patients. Furthermore, many patients also do not recognise the unique expertise that they bring to the clinical encounter - that is, knowledge about their personal preferences. The article argues that until patients believe that they are capable of understanding the information provided to them and believe that personal expertise and medical expertise are equally important, they are unlikely to become actively engaged.

The article argues that a shared decision making encounter is considerably different from the appointments that many patients are used to, and may even be comfortable with.  It highlights examples of campaigns to shift patient expectations, such as Ask Share Know (http://askshareknow.com.au) and Ask 3 Questions (http://personcentredcare.health.org.uk), which try to increase participation by encouraging patients to ask: what are my treatment options, what are their benefits and harms, and how likely are they to happen to me? They use brochures and other media (videos, websites, etc) to explain why this is important.

Early work suggests that interventions should be delivered in two stages: preparation, followed by enablement. The article sets out the key steps in preparation, including informing patients about what shared decision making is and what to expect; redefining perceptions of a 'good patient' and the social acceptability of this role; and confirming that clinicians want patient participation, as well as building their belief in their ability to take part.  Enablement means helping patients to take part in the shared decision making process by offering appropriate support such as decision support tools and question prompt lists.

The authors conclude that achieving shared decision making in routine practice will require interventions targeted at both clinicians and patients.  It acknowledges that clinicians will not be able to change the experience of every patient, but that health professionals should try to make it easier and safer for them to feel included and respected.  Patients need to believe that they can and should be involved, and clinicians need to ensure that they make efforts to understand what matters most to patients.  Tackling structural and process barriers, such as time to do shared decision making and tools to do it, is important, but unless we address deep rooted "white coat silence" through appropriate interventions, routine shared decision making in healthcare is unlikely to become a reality.

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