Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Shared decision-making in health care: promise vs. reality

M. Bennet Broner, PhD
Conditions
February 11, 2024
Share
Tweet
Share

The American Heart Association (AHA) recently published a statement on the importance of shared decision-making (SDM) between physicians and patients. This concept, though at least 50 years old, has become popular in the last decade or so, with expectations of improving patient care, satisfaction, safety, care efficiency, and cost reduction. Though some preliminary research appears to support these promises, other researchers have found that it can increase costs and decrease both patient satisfaction and care efficiency. Additionally, with increasingly fragmented care, decreasing provider reimbursement, and the emphasis on increasing the number of daily patient visits, the likelihood of expansive growth is questionable.

In the 1960s to 70s, patient engagement relied on the assumption that patients wanted to participate in their care if only information was simplified and understandable. Today, we know that SDM is more complicated than this, making it surprising that the AHA harkened back to simplification as the base for their care model. Poor literacy remains a major problem, and the current recommendation is that information be provided at the fifth-grade level. Realistically, though, not all concepts can be simplified to a point with an average word length of 4 to 5 letters and an average sentence of 10 words. Given the influx of individuals for whom English is a second language, further literacy complications are introduced.

The AHA fails to consider other crucial factors, like patient interest in engagement. Polls on patient disinterest in SDM have varied widely, depending on multiple factors, with 14 to 80 percent of respondents indicating a lack of interest in participation. How does this fit the AHA model? Are physicians (or others) expected to compel patients to participate? Given the ethical concept of patient choice, does a patient not have the right to choose non-participation? If not, then the concept of choice is meaningless!

Humanists have contended that the paternalistic model of patient care is unacceptable as it denies a basic human right, individual choice, and had to be replaced by shared decision-making, as this somewhat equalized the power between doctor and patient. However, if, as the AHA recommends, it is the doctor’s responsibility to provide the information necessary for patient choice, then paternalism remains, and the balance of power is unredressed as the physician decides what material to provide.

In his book, The Good Doctor, Dr. Lerner discusses his father’s approach to patient care, “beneficent paternalism” (my term). He did not approve of it, though he saw its necessity in certain circumstances, as he admitted that: “In some instances, the ramifications of some choices are so genuinely complicated that it makes little sense to expect laypeople to know what should be done.” While I can conditionally agree with the practicality of this approach, Dr. Lerner noted that it requires a close, even intimate, relationship between physician and patient, which he indicated is likely impossible given today’s style of medical practice. I would also be concerned that, given these same demands, it would be too easy for a doctor to slip back into traditional paternalism.

If one wants the right to make decisions, then they have the responsibility of gathering information for themselves rather than being dependent on another for it. Knowledge about virtually every medical condition and procedure is readily available online, regardless of education or English proficiency. Given the ubiquity of smartphones, with 312 million estimated users in 2023, the multiplicity of locations with free internet, and the numerous organizations that provide simple-to-understand, reliable information in multiple languages that people could review and subsequently discuss with their physicians; effectively, no one can claim an inability to find applicable material if they were motivated to do so.

Researchers unsurprisingly have indicated that the likelihood of shared decision making tends to reside in the better-educated, as those who are less so and/or have limited fluency tend to see themselves as of lesser power and remain silent. Rather than information, they require encouragement and empowerment to conduct their research. An office associate could demonstrate how easily material can be accessed, encourage them to do so, and even provide a list of trustworthy websites. Researchers have additionally indicated that encouragement and empowerment are more effective when promoted on an organizational level so that they come not only from a doctor’s office but from all aspects of the health care system.

Patient engagement does not have to be an “all or none” option. Many individuals may wish to be involved in and satisfied with some aspects of their care, though not all. Discussion of this topic can be initiated through either a simple question during an examination or on an intake form. It can be part of a conversation regarding whether one has a health care proxy or a DNR on file, etc. Even asking these questions initiates patient engagement. Or one may simply encourage a patient to ask questions or say something like, “At this point, I would like to know …. what about you?”

M. Bennet Broner is a medical ethicist.

Prev

Korean Americans and mental health [PODCAST]

February 10, 2024 Kevin 0
…
Next

Not all patients are on disability

February 11, 2024 Kevin 2
…

Tagged as: Primary Care

Post navigation

< Previous Post
Korean Americans and mental health [PODCAST]
Next Post >
Not all patients are on disability

ADVERTISEMENT

More by M. Bennet Broner, PhD

  • How to spot bad science in medical news

    M. Bennet Broner, PhD
  • The ethical crossroads of medicine and legislation

    M. Bennet Broner, PhD
  • Why terminal cancer patients still receive aggressive treatment

    M. Bennet Broner, PhD

Related Posts

  • How social media can help or hurt your health care career

    Health eCareers
  • Why the health care industry must prioritize health equity

    George T. Mathew, MD, MBA
  • Improve mental health by improving how we finance health care

    Steven Siegel, MD, PhD
  • Proactive care is the linchpin for saving America’s health care system

    Ronald A. Paulus, MD, MBA
  • Health care workers should not be targets

    Lori E. Johnson
  • To “fix” health care delivery, turn to a value-based health care system

    David Bernstein, MD, MBA

More in Conditions

  • The generational trauma of the health care system

    Tiffiny Black, DM, MPA, MBA
  • Leadership levers to reduce burnout

    Brian Sutter
  • A mother’s question about PCOS and her son’s autism

    Irene Tanzman
  • A pharmacist’s lesson in patient care

    Maisoon Hasan
  • Why sudden testicular pain is an emergency

    Martina Ambardjieva, MD, PhD
  • Pregnancy after age 35: What are the real risks?

    Alan M. Peaceman, MD
  • Most Popular

  • Past Week

    • Rethinking the JUPITER trial and statin safety

      Larry Kaskel, MD | Conditions
    • The silent disease causing 400 amputations daily

      Xzabia Caliste, MD | Conditions
    • The measure of a doctor, the misery of a patient

      Anonymous | Physician
    • How AI is transforming health care with real-world data insights [PODCAST]

      The Podcast by KevinMD | Podcast
    • Endometriosis, AMH, and your fertility

      Oluyemisi Famuyiwa, MD | Conditions
    • Why self-care is not enough for clinicians

      Pragya Thakur, MBA | Conditions
  • Past 6 Months

    • Rethinking the JUPITER trial and statin safety

      Larry Kaskel, MD | Conditions
    • The ignored clinical trials on statins and mortality

      Larry Kaskel, MD | Conditions
    • Health equity in Inland Southern California requires urgent action

      Vishruth Nagam | Policy
    • How one physician redesigned her practice to find joy in primary care again [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why doctors must fight for a just health care system

      Alankrita Olson, MD, MPH & Ashley Duhon, MD & Toby Terwilliger, MD | Policy
    • Why your clinic waiting room may affect patient outcomes

      Ziya Altug, PT, DPT and Shirish Sachdeva, PT, DPT | Conditions
  • Recent Posts

    • How AI is transforming health care with real-world data insights [PODCAST]

      The Podcast by KevinMD | Podcast
    • Rethinking the value of the annual physical

      Larry Kaskel, MD | Physician
    • The generational trauma of the health care system

      Tiffiny Black, DM, MPA, MBA | Conditions
    • Leadership levers to reduce burnout

      Brian Sutter | Conditions
    • A mother’s question about PCOS and her son’s autism

      Irene Tanzman | Conditions
    • A pharmacist’s lesson in patient care

      Maisoon Hasan | Conditions

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 3 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Rethinking the JUPITER trial and statin safety

      Larry Kaskel, MD | Conditions
    • The silent disease causing 400 amputations daily

      Xzabia Caliste, MD | Conditions
    • The measure of a doctor, the misery of a patient

      Anonymous | Physician
    • How AI is transforming health care with real-world data insights [PODCAST]

      The Podcast by KevinMD | Podcast
    • Endometriosis, AMH, and your fertility

      Oluyemisi Famuyiwa, MD | Conditions
    • Why self-care is not enough for clinicians

      Pragya Thakur, MBA | Conditions
  • Past 6 Months

    • Rethinking the JUPITER trial and statin safety

      Larry Kaskel, MD | Conditions
    • The ignored clinical trials on statins and mortality

      Larry Kaskel, MD | Conditions
    • Health equity in Inland Southern California requires urgent action

      Vishruth Nagam | Policy
    • How one physician redesigned her practice to find joy in primary care again [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why doctors must fight for a just health care system

      Alankrita Olson, MD, MPH & Ashley Duhon, MD & Toby Terwilliger, MD | Policy
    • Why your clinic waiting room may affect patient outcomes

      Ziya Altug, PT, DPT and Shirish Sachdeva, PT, DPT | Conditions
  • Recent Posts

    • How AI is transforming health care with real-world data insights [PODCAST]

      The Podcast by KevinMD | Podcast
    • Rethinking the value of the annual physical

      Larry Kaskel, MD | Physician
    • The generational trauma of the health care system

      Tiffiny Black, DM, MPA, MBA | Conditions
    • Leadership levers to reduce burnout

      Brian Sutter | Conditions
    • A mother’s question about PCOS and her son’s autism

      Irene Tanzman | Conditions
    • A pharmacist’s lesson in patient care

      Maisoon Hasan | Conditions

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Shared decision-making in health care: promise vs. reality
3 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...