Can shared decision making thrive in the current medical culture?

According to a Cochrane review patients are much more satisfied and have better health outcomes when their health care decisions are made in the context of full information and free choice. Patients said that “being in control” was what they most cherished.

At the present time the NHS doesn’t really support true shared decision making and options are likely to become even more limited with a shortage of doctors and strain on budgets. There also is considerable conflict when it comes to following guidelines which are designed for populations rather than individuals. Should a doctor really let the patient take the consequences of their individual choice or would they just be putting themselves at risk from a General Medical Council hearing?

Yet, not all patients want the most expensive treatments. When given full options a fifth of patients decided to avoid or defer surgery for instance.

What is meant to happen is that patients get given option grids with all the risks, benefits and uncertainties of possible investigations and treatments.  They are then asked, “What is the most important thing to you?” and then the doctor is meant to guide the patient accordingly.

Take bowel cancer screening. Currently all 50 year olds get sent a pack for this along with their birthday cards. Nice that someone remembers eh? They then get given the usual barrage of one sided messages about how bowel screening is really easy and could save your life.

If you care to look at this in more depth bowel cancer screening gives a total mortality benefit of six days to the screened population. The main problem is bowel perforation which occurs in 1 in 800 procedures. This is more likely to happen when going round the bends of the bowel.  Diagnosis of this can be delayed. Presumably with the shared decision making model all this is taken into account and the patient gets a truly informed choice.

Breast screening and statins are similarly pushed with considerable information asymmetry in the NHS.  There is no total mortality benefit to women from breast screening or statins yet that does not stop them being promoted. Not much has changed regarding how health care information is put across to patients in decades. An authoritarian stance is taken by the health care promoter and the patient is treated like an idiot.

With shared decision making it is likely that less money would be spent on useless investigations and treatments. If someone particularly wanted to avoid breast cancer “at all costs” they may be happy to be able to have screening perhaps more frequently than occurs at present, or perhaps they may be offered bilateral mastectomy. Many women would however decline to have mammography and that would be a saving not only for the procedure but for the unnecessary surgery and treatments that follow.

Shared decision making certainly doesn’t occur in diabetic clinics. The high carb / low fat diet is a product of “politics based medicine” rather than “evidence based medicine”.  Shared decision making is not for everyone. There will always be people and situations were doing what a doctor thinks is best is the most appropriate option.

But for a lot of non-acute health issues it is appropriate.  I can only hope that shared decision making doesn’t wither on the vine but a large shift in medical culture will be needed before it becomes regular practice.

Based on BMJ Learning module by Alf Collins.

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