If it's so wonderful, what’s the problem? Why is it not happening everywhere? If shared decision making, as we are told, leads to such good things, why is it not happening everywhere? Since 2001, a community of interest, roughly 250 or so each time, has met in various locations around the globe to share ideas, present research and compare notes about the topic of shared decision making. The interest in the idea keeps growing but implementation is a massive challenge. It is more difficult than pushing water uphill. Amiram Gafni, close colleague of Cathy Charles, kicked off the conference in Lyon, France, by asking the provocative question: if shared decision making is so good, what’s the problem?
It is a good question and one that we need to think about carefully. Annie LeBlanc described how the group at Mayo put together a comprehensive toolkit to support practices. In a randomized study, it was clear that their intense implementation efforts had less than expected impact (conference presentation). A few years earlier, the MAGIC programme in the UK (Cardiff and Newcastle) described significant barriers to implementation, summarized beautifully by Natalie Joseph-Williams at the conference and in a recent article . The litany of implementation failures seems unending.
Why so difficult?
Perhaps it is time to be painfully honest about why is seems impossible to get anywhere.
Shared decision making: More work, that will take more time. Making people aware that there is more than one way to deal with a problem can only lead to more work not less, at least if you take a short term view. There is emotional work, there is intellectual work, cognitive work, there is relational work, and many other types of work that comes by asking people to consider what might best suit their circumstances. Health professionals are not saints - they are typically under considerable time pressure. Why would they make their work life more difficult, for no clear gain to them?
Shared decision making: I don’t anyone else doing it! There is strong emphasis on communication skills in training grades - and rightly so. However, look carefully look at what happens in the real world - you will see a yawning gap. Students arrive bushy tailed, eager to care and communicate. Yet after gruelling apprenticeships, they enter a world where many professionals behave very differently to the models promoted in communications skills courses. Who do they emulate? Bandura was right - students copy what they see .
Shared decision making: it’s not going to benefit me. Why on earth would you explain the possible drawbacks of an intervention if your income depended on it taking place? Fees for services are anathema to any idea of sharing decisions with patients if the result of more deliberation would lead to financial loss in some direct or indirect way. But there’s more to it than that. Even where there is no obvious financial incentive, other rewards exist. Doing more enhances experience, enhances careers, enables research. Health professionals, speaking generally are wired for action. And just in case you had not noticed, the clinical guideline machine is designed to support ‘recommendations’: to recommend action rather than compare reasonable alternatives. Medicine is about doing things, even when gains are marginal, they seem necessary, to health professionals at least.
So why “incredible”? Surely the resistance to shared decision making is totally understandable? Healthcare systems have been designed to make it almost impossible to support careful deliberation and collaboration with patients . There is no incentive, extrinsic or intrinsic, to motivate health professionals to gently work out with patients what is best, to know more about the balance of harms and benefits.
I say incredible because there is evidence to show that we could do much better, that we could cut waste and reduce harm if we did shared decision making well. But clearly evidence is not enough. It will become incredible that we do not try harder to do shared decision making when patients understand the huge potential of shared decision making. There were a few patients at Lyon. In the future, we will need many many more. When patients understand better (and that time will come,) they will want health professionals who spend time being careful, being kind, and explaining trade-offs. Then, and perhaps only then, will shared decision making happen.
Lyon Airport, France
July 6th 2017
1. Joseph-Williams N, Lloyd A, Edwards A, et al. Implementing shared decision making in the NHS: lessons from the MAGIC programme. BMJ 2017; 357: j1744. http://www.ncbi.nlm.nih.gov/pubmed/28420639 (accessed 11 Jul2017).
2. Bandura, A. (1962). Social Learning through Imitation. University of Nebraska Press: Lincoln, NE.
3. Elwyn G, Lloyd A, May C, et al. Collaborative deliberation: A model for patient care. Patient Educ Couns 2014;97:158–64. doi:10.1016/j.pec.2014.07.027