Sharing clinical decisions by discussing evidence with patients.

Our patients receive skillfully presented medical information from multiple sources other than us—in particular, from direct-to-consumer pharmaceutical advertising that pervades television, radio, print media, and the Internet. At the same time, clinicians cannot easily keep pace with the volume of new medical information available from studies—and the quality of studies may vary greatly. We clinicians must therefore differentiate high-quality from less-than-high-quality evidence and become skilled in communicating this difference to patients to help address their concerns. Consider the following scenario: A 55-year-old thin, nonsmoking female calls you with questions about her hormone therapy. Two months ago, she started a regimen of estrogen 0.625 mg and progesterone 2.5 mg daily to treat perimenopausal hot flushes. She has no history of hypertension but has impaired glucose tolerance with a fasting blood glucose level of 114 mg/dL. Her total cholesterol level is 185 mg/dL; low-density lipoprotein (LDL) cholesterol level, 120 mg/dL; high-density lipoprotein (HDL) level, 45 mg/dL; and triglyceride level, 100 mg/dL. Her mother has coronary artery disease, which manifested at age 60 years. The patient has had excellent relief of her hot flushes. She recently read an article (in a lay publication) that warned all women to stop hormone therapy, but she is concerned that symptoms might recur if she does this. What should you tell her? Shared decision making is an excellent approach for discussing treatment options with patients like the one described here. Shared decision making is a communication strategy that provides evidence to patients in a nonbiased way and that shares with patients the basis as well as the responsibility for making medical decisions. Moreover, this approach inherently recognizes and respects patient's values; helps patients to consider the seriousness of the condition to be prevented or treated; helps patients to understand risks, benefits, and alternative options for diagnosis and treatment; engages patients in the decision-making process at a level which they personally find comfortable and desirable; and includes patients' own beliefs and values as factors in the decision-making process.1 In this sense, shared decision making differs from the process of obtaining informed consent; in that process, risks and benefits are disclosed without explicitly incorporating the patient's values or sharing the basis for decision making in a formal decision-making process. Shared decision making should not be used to intentionally steer patients to a particular decision. According to one study, 19% to 68% of patients—especially younger, more highly educated patients—are interested in sharing the decision-making process with their physicians.2 Shared decision making is consistent with the Institute of Medicine's call for a patient-provider partnership “to ensure that decisions respect patients' wants, needs, and preferences and that patients have the education and support they require to make decisions and [to] participate in their own care. ”3:p7 Further, shared decision making may promote trust within patient-physician relationships, enhance patients' confidence about participating in their own health care, and reduce patients' decisional conflict with a chosen course of care. In general, strategies for shared decision making are applicable in four situations: When recommendations conflict with one another or insufficient evidence exists to form a basis for recommending for or against an intervention When several possible interventions are believed to have approximately equal effectiveness When the benefits of an intervention may vary from patient to patient When, on the basis of their values or personal situation, patients may differ in the way they weigh the risks and benefits of an intervention.