How to integrate shared decision-making into your practice

Limitations to the evidence

Systematic reviews routinely note substantial heterogeneity in the literature on SDM use, owing to variable definitions of what steps are essential to constitute an SDM intervention and a wide variety of outcome measures used, as well as the broad range of conditions to which SDM is potentially applicable.^{3,4,10,36,37,43-45} While efforts in SDM education, uptake, and study frequently adapt frameworks such as those outlined in TABLE 2,^{11,15-17,20-22} there is as yet no one consensus on the “best” approach to SDM, and explicit study of any given approach is limited.^{18,23,36,44-46} There remains a clear need to improve the uptake of existing reporting standards to ensure the future evidence base will be of high quality.⁴⁴ In the meantime, a large portion of the impetus for expanding the use of SDM remains based on principles of effective communication and championing a patient-centered philosophy of care.

Cultivating an effective approach

An oft-cited objection to the use of SDM in day-to-day clinical care is that it “takes too much time.”⁴⁷ Like all excellent communication skills, SDM is best incorporated into a clinician’s approach to patient care. With practice, we have found this can be accomplished during routine patient encounters—eg, when providing general counsel, giving advice, providing education, answering questions. Given the interdependent relationship between evidence-based medicine and SDM, particularly in preference-sensitive conditions, SDM skills can facilitate efficient decision-making and patient satisfaction.⁴⁸ To that end, clinician training on SDM techniques, especially those that emphasize the 3 core elements, can be particularly beneficial. These broadly applicable skills can be leveraged in an “SDM mindset,” even outside traditional preference-sensitive care situations, to enhance clinician–patient rapport, relationship, and satisfaction.

The future of SDM

More than 2 decades after SDM was introduced to clinical care, there remains much to do to improve uptake in primary care settings. An important strategy to increase the successful uptake of SDM for the typical clinician and patient is to emphasize the approach to framing the topic and discussion rather than to overemphasize decision aids.²³ Continuing the trend of well-designed and accessible tools for clinical decision support at the point of care for clinicians, in addition to the sustained evolution of decision aids for patients, should help minimize the need for extensive background knowledge on a topic, increase accessibility, and enable an effective partnership with patients in their health care decisions.⁴⁶ Ongoing, well-structured study and the use of common proposed standards in developing these tools and studying SDM implementation will provide long-term quality assurance.⁴⁴

SDM has a role to play in health equity

SDM has a clear role to play in addressing health inequities. Values vary from person to person, and individuals exist along a variety of cultural, community, and other spectra that strongly influence their perception of what is most important to them. Moreover, clinicians’ assumptions typically do not correspond to a patient’s actual desire to engage in SDM nor to their overall likelihood of choosing any given treatment option.⁴⁶ While many clinicians believe patients do not participate in SDM because they simply do not wish to, a systematic review and thematic synthesis by Joseph-Williams et al⁴⁶ suggested a great number of patients are instead unable to take part in SDM due to barriers such as a lack of time availability, challenges in the structure of the health care system itself, and factors specific to the clinician–patient interaction such as patients feeling as though they don’t have “permission” to participate in SDM.

Shared decision-making may reduce disparities in populations disproportionately affected by certain health conditions.

SDM may improve health equity, adherence, and outcomes in certain groups. For example, SDM has been suggested as a potential means to address disparities in outcomes for populations disproportionately affected by hypertension.²⁴ The increased implementation of SDM practices, coupled with a genuine partnership between patients and care teams, may improve patient–clinician communication, enhance understanding of patient concerns and goals, and perhaps ultimately increase patient engagement and adherence.

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