Department of Community and Family Medicine and The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH (Dr. Mackwood); Dartmouth-Hitchcock Medical Center, Lebanon, NH (Drs. Mackwood and Morrow); Population Health, DartmouthHitchcock Medical Center, Lebanon, NH (Ms. Imset) email@example.com
The authors reported no potential conflict of interest relevant to this article.
Despite the many benefits of shared decision-making, uptake of its practices is low. These tools and frameworks can help you to engage patients in their care decisions.
Shared decision-making (SDM), a methodology for improving patient communication, education, and outcomes in preference-sensitive health care decisions, debuted in 1989 with the Ottawa Decision Support Framework1 and the creation of the Foundation for Informed Medical Decision Making (now the Informed Medical Decisions Foundation).2 SDM enhances care by actively involving patients as partners in their health care choices. This approach can not only increase patient knowledge and satisfaction with care but also has a beneficial effect on adherence and outcomes.3-5
Despite the significant benefits of SDM, overall uptake of SDM practices remains low—even in situations in which SDM is a requirement for reimbursement, such as in lung cancer screening.6-8 The ever-shifting list of conditions that warrant the implementation of SDM in a family practice can be daunting. Our review seeks to highlight current best practices, review common situations in which SDM would be beneficial, and describe tools and frameworks that can facilitate effective SDM conversations in the typical primary care practice.
SDM is designed to enhance the role of patient preference, considering a patient’s own personal values for managing clinical conditions when more than one reasonable strategy exists. Such situations are often referred to as preference-sensitive conditions—ie, since evidence is limited on a single “best” treatment approach, patients’ values should impact decision-making.9 Examples of common preference-sensitive situations that include preventive care, screening, and chronic disease management are outlined in TABLE 1.
How to engage patients
In preference-sensitive care situations, SDM endeavors to address uncertainty by laying out what the options are, as well as providing risk and benefit data. This helps inform patients and guides providers about individual patient preference on whether to screen (eg, for average-risk female patients, breast cancer screening between ages 40-50 years). SDM can assist with determining whether to screen and if so, at what interval (eg, at 1- or 2-year intervals), while acknowledging that no single decision would be “best” for every patient.
While there are formalized tools to provide information to patients and help them consider their values and choices,3,10SDM does not hinge on the use of an explicit tool.11-18 There are many approaches to and interpretations of SDM; the Ottawa Decision Support Framework reviews and details these many considerations at length in its 2020 revision.19TABLE 211,15-17,20-22highlights various SDM frameworks and the steps involved.
These 3 elements are commonamong SDM frameworks
In a 2019 systematic review, the following 3 elements were highlighted as the most prevalent over time across SDM frameworks and could be considered core to any meaningful SDM process23:
Explicit effort by 2 or more experts. The patient is an expert in their own values. The clinician, as an expert in relevant medical knowledge, clarifies that the current medical situation will benefit from incorporating the patient’s preferences to arrive at an appropriate shared decision.