Shared medical decision making: problems, process, progress.

IT IS EASY TO MARCH BEHIND THE BANNER OF SHARED MEDIcal decision making. Sharing with a patient who faces tough choices when he or she is ill is one of the true gifts of being in the medical profession. The patientphysician relationship is the sacrosanct epitome of professionalism with the goals of ensuring that patients receive the treatment best for them (science) and that the best treatment is carried out in the most efficient and compassionate manner (quality and safety). However, the concept of shared decision making requires careful consideration of several problems. The first problem is that the term “shared decision” is a misnomer. Consider the example of sharing toys between children: first one child plays, then the toy is passed on to the next child. This concept of sharing in the case of medical decision making between patient and physician, would not be possible. Since words shape concepts, a circular tautology can cause goals to be missed if incorrect words are used to communicate. Specifically, how does a physician really share a decision that involves the patient’s medical care? The misnomer of sharing creates confusion and mollifies a practice of medical care that rewards physicians for making choices for patients. Physicians should never make a choice for a patient—even if the patient wants the physician to do so. Instead, physicians should ensure that the information used in the patient’s decision making is reasonable for the individual patient and that the patient understands the ramifications of choice. The physician should be a navigator, not a pilot. The argument for a change in the process of decision making is based on recognizing that the consequences of a patient’s choice cannot be shared with anyone else. Only the patient will suffer or enjoy the probabilistic outcomes associated with choosing one option over another. Only the patient will know how he or she feels about experiencing an adverse effect of a treatment or a reduced chance of an adverse outcome that a treatment is designed to alter. For example, if the benefit of undergoing a prostatectomy for improving the chance of survival from prostate cancer is worth the increased chance of becoming impotent or incontinent, only the patient will know. Since no one else knows, no one else should decide. Therefore, in medicine shared decision making cannot exist. Some actions in medical care are not really decisions to be made by the patient and, hence, do not require a patient’s input into choice. For example, patients do not need to decide if antibiotics are required for bacterial pneumonia. A rational clinician does not allow sick patients to make decisions about treatments that are of clear value and that do not create significant levels of harm. If the significance of any adverse effect or harm is so minor compared with the benefit gained with treatment, no decision is required. A decision that appropriately involves a patient also requires viable options, and choosing one option over another must engender some element of risk. There has to be a definable trade-off of harm and benefit, or no decision is required. Some acute care treatments or preventive care options do not create these sorts of trade-offs. On the other hand, there are times when neither physicians nor patients should make choices. These situations occur when reasonable estimates for an individual’s benefit and harm associated with options are not available. Shared medical decision making really does not pertain to sharing choices, but rather involves sharing information. In fact, the term “informed medical decision making” is used synonymously with shared medical decision making. Informed medical decision making is a better use of words and may allow some unification or at least organization of the debate about the ideal way medical care decisions should be made. Under the paradigm of informed choice, 2 questions can be asked: how do physicians inform patients about the consequences of the choices they must make, and how do physicians help patients use the information to make the choice? These questions can be answered with 1 solution. Informing patients about choices is the process that allows them to reflect on the potential gains and losses associated with the marginal probabilities of outcomes. Conceptually and procedurally, this process has 2 requirements. The first is that the patient must have something to reflect upon. Some quality of life trade-off can exist only if the difference in the