About Shared Decision Making
What is Shared Decision-Making (SDM)?
SDM is a collaborative process that involves patients and clinicians making health-related decisions after discussing the available options; the benefits and harms of each option; and considering the patient’s values, preferences and personal circumstances.
Hoffmann T, Bakhit M, Michaleff A. Shared decision making and physical therapy: What, when, how and why? Braz J Phys Ther 26(1), 2022
Shared decision-making is crucial for evidence-based practice. To engage in shared decision-making clinicians must understand the magnitude of benefits, harms and burdens associated with alternative management options—along with the quality of the evidence—and be able to discuss these with patients.
Tikkinen KAO, Gyatt GH. Understanding of research results, evidence summaries and their applicability-not critical appraisal-are core skills of medical curriculum. BMJ Evid Based Med. 2021 Oct;26(5):231-2.
What is the purpose of SDM?
What is the purpose of SDM?
The underlying goal of SDM is to fundamentally care for the patient in a manner that resolves each person's situation by virtue of its effectiveness, consistency with what matters to this person, and fit with the contexts in which treatment and condition play out. SDM is a process, a conversation between clinicians and patients in which they think, talk, and feel through the situation of each patient. In essence, SDM is a human expression of care that is careful and kind.
Kunneman M, Montori VM, Castaneda-Guarderas A, Hess EP. What Is Shared Decision Making? (and What It Is Not). Acad Emerg Med. 2016 Dec;23(12):1320-1324.
SDM Competencies for Health Professionals
Relational competencies: creating a favorable environment for communication and appropriate interaction during the clinical encounter.
Risk communication competencies: discussing the concept of uncertainty in treatment outcomes with the patient and effectively communicating information about the risks and benefits of different treatment or health care options.
Légaré F, et al. Core Competencies for Shared Decision Making Training Programs: Insights From an International, Interdisciplinary Working Group. J Contin Educ Health Prof. 2013 Fall;33(4):267-73.
SDM Models
A three-step model:
1. Choice talk: making sure that patients know that reasonable options are available;
2. Option talk: the step of providing more detailed information about options, and
3. Decision talk: the step of considering preferences and deciding what is best.
Elwyn G, et al. Shared Decision Making: A Model for Clinical Practice. J Gen Intern Med. 2012 Oct; 27(10): 1361–1367.
- ShaDES model:The patient's perspective about available treatment options is explicitly included.
- The SHARE Modela five-step process for shared decision-making that includes exploring and comparing the benefits, harms, and risks of each option through meaningful dialogue about what matters most to the patient.
SDM in Chiropractic/MSK
Selected studies support inclusion of SDM in musculoskeletal care:
- Effectiveness of shared decision-making intervention in patients with lumbar degenerative diseases: A randomized controlled trialTo evaluate the efficacy of shared decision-making (SDM) intervention among patients with lumbar degenerative diseases (LDDs) in terms of decision self-efficacy, control preferences, SDM process, decision satisfaction, and conflict.
- Supporting shared decision making using an Option Grid for osteoarthritis of the knee in an interface musculoskeletal clinic: A stepped wedge trialTo evaluate whether introducing tools, specifically designed for use in clinical encounters, namely Option Grids, into a clinical practice setting leads to higher levels of shared decision making.
- Effectiveness of a decision aid for patients with knee osteoarthritis: a randomized controlled trialTo assess the effectiveness of a Patient Decision Aid (PtDA) for knee osteoarthritis.
Benefits of SDM for Patients & Healthcare Providers
Benefits for patients
- better knowledge about treatment options
- more realistic expectations concerning disease course and treatment
- improved adherence
- improved clinical outcomes
- enhanced patient satisfaction
Benefits for healthcare providers
- increase in professionals’ personal well-being and job satisfaction
- decrease in malpractice claims and patients’ litigations.
(Stalnikowicz, Brezis, 2020; Shay, Lafata, 2014; Guidi, Traversa, 2021)
Apply and Assess/Evaluate
Evidence alone does not make decisions, people do. (Haynes, 2002)
This is the step when you APPLY evidence to an individual patient using shared decision-making, which requires the integration of the best research evidence with your clinical expertise and your patient’s unique values and circumstances.
Clinical expertise includes the general skills of clinical practice as well as the experience of the individual practitioner. To formulate an evidence-based Plan of Management for a patient, clinicians need to balance their experience with the condition, the patient’s circumstances and preferences, and research evidence.
Consider asking these questions to decide on the applicability of study results to your individual patient:
Therapy: Are the valid, important results of this individual study applicable to our patient?
- Is our patient so different to those in the study that the results cannot apply?
- Is the treatment feasible in our setting?
- What are the potential benefits and harms from the therapy to our patient
- How can we present this information in a way that can support shared decision making? What are our patient’s values and expectations for both the outcome we are trying to prevent and the treatment we are offering?
Diagnosis: How can I apply this valid, important diagnostic test to a specific patient?
- Is the diagnostic test available, affordable, accurate, and precise in our setting?
- Can we generate a clinically sensible estimate of our patient’s pretest probability?
- Will the resulting post-test probabilities affect our management and help our patient?
Prognosis: Can we apply this valid and important evidence about prognosis to our patient?
- Is our patient so different to those in the study that the results cannot apply?
- Will this evidence make a clinically important impact on our conclusions about what to offer or tell our patient?
Harm: Can this valid and important evidence about harm be applied to our patient?
- Is our patient so different to those in the study that the results cannot apply?
- What are our patient’s risks of benefit and harm from the agent?
- What are our patient’s preferences, concerns, and expectations from this treatment?
- What alternative treatments are available?
Read more: Straus S, Glasziou P, Richardson WS, Haynes RB. Evidence-based medicine: how to practice and teach EBM, 2019.
Shared Decision-Making requires high-level patient-centered communication. A number of important communication skills/techniques are required to create and build effective doctor-patient partnerships. Here are a few of the methods recommended:
- establishing a trusting relationship;
- assessing patient’s understanding of the situation;
- explaining treatment options, risks and benefits using plain language;
- communicating medical uncertainty (i.e. when the evidence is unclear or unavailable);
- eliciting patient’s values, goals and preferences;
- deliberating with a patient (discussing pros and cons, patient’s concerns)
- recognizing and responding to opportunities for empathy and compassion;
Skills and behaviors that demonstrated an increase in real patient perception of compassion include:
- sitting (versus standing) during the interview;
- detecting patients’ facial expressions and non-verbal cues of emotion;
- incorporating verbal statements of acknowledgement, validation, and support;
- employing non-verbal caring behavior as opposed to avoidant or aggressive behavior (body position facing the patient; eye contact; tone of voice; appropriate hand and arm movements).
- cross-cultural and culturally specific nonverbal practices.
(Kon et al., 2006; Coates D, Clerke T, 2020; Patel et al., 2019; Lorié Á et al., 2017)
- Shared Decision Making in Intensive Care Units: An American College of Critical Care Medicine and American Thoracic Society Policy Statement.Shared decision-making (SDM) is endorsed by critical care organizations, however there remains confusion about what SDM is, when it should be used, and approaches to promote partnerships in treatment decisions. The purpose of this statement is to define SDM, recommend when SDM should be used, identify the range of ethically acceptable decision-making models, and present important communication skills.
- Training Interventions to Equip Health Care Professionals with Shared Decision-Making Skills: A Systematic Scoping Review.To support the development, implementation, and evaluation of shared decision-making (SDM) training programs, this article maps the relevant evidence in terms of training program design and content as well as evaluation outcomes.
- Curricula for empathy and compassion training in medical education: A systematic review.Empathy and compassion are vital components of health care quality; however, physicians frequently miss opportunities for empathy and compassion in patient care. Despite evidence that empathy and compassion training can be effective, the specific behaviors that should be taught remain unclear. We synthesized the biomedical literature on empathy and compassion training in medical education to find the specific curricula components (skills and behaviors) demonstrated to be effective.
- Culture and nonverbal expressions of empathy in clinical settings: A systematic review.To conduct a systematic review of studies examining how culture mediates nonverbal expressions of empathy with the aim to improve clinician cross-cultural competency.
Empathy and compassion are foundational principles of shared-decision making, with proved benefits for both patients and healthcare providers. Although the capacity for empathy and compassion depends on inherent traits, it is still can be nurtured and enhanced.
Compassion and compassionate care are emerging as a competency that healthcare providers are expected to deliver. Cultivation of empathy and compassion is part of personal growth and professional identity.
Compassionate Clinical Care
- Shared Decision Making: The Need For Patient-Clinician Conversation, Not Just Information.The growth of shared decision making has been driven largely by the understanding that patients need information and choices regarding their health care. But while these are important elements for patients who make decisions in partnership with their clinicians, our experience suggests that they are not enough to address the larger issue: the need for the patient and clinician to jointly create a course of action that is best for the individual patient and his or her family.
Neuroscience of Empathy
- Empathy in Medicine: What It Is, and How Much We Really Need ItIt is acknowledged that empathy plays a critical role in the physician-patient relationship and has a positive impact on health outcomes. However, as the field of empathy expands, the lack of conceptual coherence challenges advances in medicine.
- Human Empathy Through the Lens of Social NeuroscienceEmpathy is the ability to experience and understand what others feel without confusion between oneself and others. Knowing what someone else is feeling plays a fundamental role in interpersonal interactions.
- Compassionate Care: Making It a Priority and the Science Behind It.Compassion is the deep feeling that arises when confronted with another’s suffering coupled with a strong desire to alleviate that suffering. Until recently, evidence was lacking as to whether compassion was innate, acquired, or modifiable. Because patients who experience compassionate health care report better clinical outcomes, an understanding of the science behind it may give rise to methods of incorporating compassion into clinical care delivery.
Benefits of Empathy for Patients and Clinicians
- Effectiveness of empathy in general practice: a systematic review.This literature review explores the effectiveness of empathy in general practice. Effects that are discussed are: patient satisfaction and adherence, feelings of anxiety and stress, patient enablement, diagnostics related to information exchange, and clinical outcomes.
Multidimensional Nature of Clinical Empathy
- Empathy in patient care: from 'Clinical Empathy' to 'Empathic Concern'.As empathy gains importance within academia, we propose this review as an attempt to bring clarity upon the diverse and widely debated definitions and conceptions of empathy within the medical field. In this paper, we first evaluate the limits of the Western mainstream medical culture and discuss the origins of phenomena such as dehumanization and detached concern as well as their impacts on patient care.
How to cultivate empathy?
- The Empathy Tank as a revised model for fostering empathy in medical education.Empathy has been difficult to sustain and foster in medical training. Based on empirical evidence and intuitive human experience, this paper proposes that empathy can be re-conceptualized as a dynamic reservoir, referred to as an "empathy tank."
- Can empathy be preserved in medical education?The aim of this study was to investigate changes in empathy during medical education, as well as to identify promoters and inhibitors of empathy and analyse their roles.
- A comprehensive model for optimizing empathy in person-centered care.This study examined perspectives regarding the use of empathy within medicine and developed a model to demonstrate the components of empathy in a medical setting.
- Practical strategies for practising narrative-based medicineFamily physicians have become intrigued by what Rita Charon has called narrative medicine and what her colleagues in the United Kingdom have called narrative-based primary care.1,2 My own experience in offering narrative workshops to doctors is that they agree with the principles, but wonder how they can realistically incorporate strategies into a busy office “without opening up a whole can of worms.” There are ways to improve your narrative competence—that is, your capacity to receive, interpret, co-construct, and bear witness to the stories your patients bring you.
Assess/Evaluate
The final step in practicing EBP is self-evaluation to evaluate the effectiveness of your clinical decision. This includes evaluating your performance in
- asking answerable questions,
- searching for the best evidence
- critically appraising the evidence for its validity and potential usefulness
- applying the result in clinical practice.
The outcomes of self-assessment can help you decide whether you need to improve on any of the four steps above.
Patient Education Resources
Go to the CMCC Library’s Consumer Health Information/Patient Education LibGuide for quick links to a wide variety of trustworthy resources covering physical and mental health, wellness, healthy living, mindfulness, and more.
Tips:
- Check out the CAM & Chiropractic page that provides quick links to a variety of chiro-relevant patient education materials including digital and printable patient education handouts.
- The Public Health page features the library’s and free online resources on public health and refers to the websites where you can access the Canadian/US/Global health data as well as plain language resources.
CMCC Library Videos
Watch these CMCC Library videos to learn about the process of shared-decision making and humanistic aspects of the doctor-patient relationship and how to create an evidence-based Plan of Management within your patient care, and see examples of the Apply step of EBP in action.
CMCC E-Books
Evidence-Based Medicine by Publication Date: 2018
Empathy in Health Professions, Education, and Patient Care by Publication Date: 2016
CMCC Print Books
Evidence-Based Practice Across the Health Professions by Call Number: WB 102.5 H711e 2017
Evidence-Based Practice in Exercise Science by Call Number: QT 261 A523e 2016
Evidence Based Physical Therapy by Call Number: WB 460 F421 2019
Evidence-Based Sports Medicine by Call Number: QT 261 E93 2007
Evidence-Based Chiropractic Practice by Call Number: WB 905.9 H237e 2007
Bringing Evidence into Everyday Practice by Call Number: WB 102 D923b 2008
Ethics and Evidence-Based Medicine by Call Number: WB 60 G653 2003
Evidence-Based Healthcare by Call Number: WB 102 G779 2001
Knowledge Translation in Health Care by Call Number: WB 102.5 K663 2013
Communication Tools
- The Calgary-Cambridge guide to the medical interview: communication process.Adapted from Kurtz S, Silverman J, Draper J. Teaching and learning communication skills in medicine. 2nd ed. Abingdon UK : Radcliffe Publishing; 2005.
- Marrying Content and Process in Clinical Method Teaching Enhancing the Calgary–Cambridge GuidesCommunication skills training is now internationally accepted as an essential component of medical education. However, learners and teachers in communication skills programs continue to experience problems integrating communication with other clinical skills, ensuring that clinical faculty support and teach communication beyond the formal communication course, extending communication training coherently into clerkship and residency, and applying communication skills in medical practice at a professional level of competence.
- A to Z Inventory of Patient Decision AidsClick on a title to view a brief description that will help you decide if the decision aid will meet your needs, or try another keyword search to look for other decision aids.