Shared Decision Making in Health Care

With the ongoing saga of the Democratic Primary, and the upcoming presidential election, we will all be hearing more and more about the cost of health care in this country. While the debate at the national and state levels will certainly influence the lives of many down the road, what about the decisions that we make (or don’t get to make) when we’re in the doctor’s office?

Recent work by Bob Kaplan and Dominick Frosch at the UCLA School of Public Health suggests that while people in some parts of the country get a lot more stuff done to them medically (tests, procedures, etc.), people in those areas don’t necessarily have better health outcomes. There is a lot of uncertainty in the medical profession, and in many cases, there isn’t necessarily one “best” course of treatment.

Kaplan and Frosch point out that there are a lot of things about an individual patient that a doctor can’t know from lab tests (like how important certain quality of life issues are to you, how much risk you can tolerate, etc.), and suggest that patients and doctors engage in “shared decision making.” That is, when patients and docs communicate about quality of life issues and patient preferences, and when patients play an active role in consulting with their physicians, patients feel more in control over the illness, and may actually have better physical health outcomes. Also, on a broader level, after fully understanding the risks and benefits, many patients may elect to go for less invasive, and often lower-cost, options.

Some may object that doctors don’t have time for this type of treatment, but most studies looking at shared decision making suggest that interventions designed to make patients more active participants in the conversation actually don’t increase visit lengths. So, next time you have a reason to see the doctor, find out about the treatment options available to you. Bringing a tape recorder to your visit may help you remember the pros and cons of options presented by your provider so that you can consider them outside of the doctor’s office. Ask questions when you don’t understand, and find out what the implications for quality of life are given the options presented to you.

Examples of decision aids for selected conditions (that you might use to help prepare you to speak with your provider) can be found here.

For more info on costs and care, check out this interactive tool, recently posted at the New York Times.

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4 thoughts on “Shared Decision Making in Health Care

  1. Pingback: Aids » Blog Archive » Shared Decision Making in Health Care

  2. Pingback: Science Sounds Like This » Blog Archive » Shared Decision Making in Health Care

  3. Maybe. But my guess is that shared decision making would be very bad in practice. The key has to do w/the decision aids you mentioned at the end. A lot of us who work on the psychology of choice tend to worry that when you give people more options, they feel like they have to take advantage of them, even if it will become really stressful. So, in the past, you used to go to your doctor, and your doctor said I know what to do, and you did it. Maybe it didn’t work out, maybe it did, but it was out of your hands. Nowadays, patients are getting more freedom to partake in the decision making process. Potentially, this allows them to get the best treatment possible. More likely, patients carry tons of biases, have trouble understanding base rates, are overconfident, rely too much on their intuitions which are based on particularly memorable experiences rather than accurate reflections, and will push for decisions that conflict with the doctor’s wishes, and b/c the doctor is worried about getting sued, they’ll go w/the patients wishes.
    Beyond biases in judgment, shared decision making means experiencing more psychological blame if something goes wrong. In one study, citations eluding me at the moment, people were asked if they would like to have a lot of say in their treatment if they ever got cancer. Most people said yes. But when you ask actual cancer patients, most say no, too stressful.
    Now I imagine decision aides will help. A little. But you still are left w/the question of who will do the research. My guess is its the mothers who are probably the ones getting saddled with doing all of the research and having to give all of the input on health decisions for the whole family in these cases. That’s a whole lot of stress for good ol’ mom.

  4. Hi Tage, Perhaps I should clarify. Shared decision making doesn’t imply that all of a sudden the patient is the only one in charge of making a decision. It’s a way to consider information that the doctor can’t know without asking the patient– for example, in the case of screening and treatment for prostate cancer (which can be hugely invasive with big side effects), for some patients, impotence may be a major concern, while for others the stress of worrying about an illness that may or may not come would be a bigger concern. Doctors can elicit this type of information and present the possible consequences of various treatment choices (when there is not one clear-cut solution), and can also explore the extent to which individuals want to be involved in such decisions.

    Re: the burden falling on moms, I agree that this is a problem in our society, and one that is not specific to this issue. The BC Centre of Excellence for Women’s Health (www.bccewh.bc.ca) does a lot of cool work around how changes in health policy impact men and women differently.

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