Shared decision making: it takes two

Of the many articles I read each year, only a few have an immediate and lasting impact on the way I practise.  Two papers had a great effect on me as a GP and educator in 1999. The topic of both was shared decision making.  

I am from a generation of medical students who did not have specific education in communication skills, as this was not required by the General Medical Council in the UK until the 1980s and was not introduced widely into curricula until the 1990s.  However, during my GP training, there were skills sessions based primarily on the 1984 book by David Pendleton and colleagues, The consultation: an approach to learning and teaching.  In addition, the commercial availability of cheaper and more mobile video cameras enabled GP trainees to record consultations and watch them back with our trainers. The Pendleton model is a series of tasks to be undertaken in consultations.  It pioneered the exploration of a patient’s ideas, concerns and expectations during the information gathering phase, derived from the person-centred approach of the psychotherapist Carl Rogers in the 1950s. While one task is ‘To involve the patient in the management and encourage him [sic] to accept appropriate responsibility’, my memory is that the primary focus of learning was on information gathering and, if possible, making a diagnosis.  

Increasing numbers of books and papers focussing on how to teach communication (for educators) and how to learn (for students) were published from the late 1980s with increasing attention to the patient-centred process.  These were helpful as I began to facilitate communication skills sessions, first as a GP trainer and then as a medical school based senior lecturer from 1996.  

The first paper in the British Medical Journal introduced me to the concept of shared decision making (SDM).  SDM was defined as when ‘patients and health professionals join in both the process of decision making and ownership of the decision made’.[1]  The authors stressed that, particularly when there are several options for investigation and management of a condition, the choices should be discussed with the patient and a joint decision made as to how to proceed.  I still have the paper copy of the issue with a black and white photograph of a couple in a tango pose with the title ‘it takes two to tango’ on the cover.  This phrase was taken from the title of an earlier paper from 1997, ‘Shared decision-making in the medical encounter: what does it mean (or it takes two to tango)’,[2] that I found in the university library.      

(That earlier paper was in the journal Social Science and Medicine, not in the medical school library where the BMJwas housed but the main university library’s section for the social sciences where I also discovered useful books about communication and language.  A lesson to go outside your discipline and learn from other perspectives.)

The second article drew attention to the ‘neglected second half of the consultation’, the space where ‘decisions are made, and future management agreed’.[3]   The identification of this neglect resonated with my own observation of consultations, and experience of being a patient, that many doctors are skilful in patient-centred approaches to information gathering but then move to a paternalistic mode and tell the patient what will happen next.  Two of the paper’s authors, Glyn Elwyn and Adrian Edwards, are experts on SDM and their research has shown that one reason why people may not follow a health professional’s advice is that they are not involved in a discussion about their management options.  

SDM in medical education became the topic of my PhD but, more importantly, influenced how I interacted in consultations.  It is an important process for all health professionals. 

Recommended book:

G Elwyn, A Edwards, R Thompson.  Shared decision making in health care. Third edition.  Oxford: Oxford University Press, 2016.

Includes my chapter: What can medical educators do to promote shared decision making?

[1] Coulter A, Entwistle V, Gilbert D.  Sharing decisions with patients: is the information good enough?  BMJ 1999;318: 318-322.

[2] Charles C, Gafni A, Whelan T. Shared decision making in the medical encounter: what does it mean (or it takes at least two to tango). Soc Sci Med. 1997;44:681-92.

[3] Elwyn G, Edwards A, Kinnersley P. Shared decision-making in primary care: the neglected second half of the consultation. Br J Gen Pract. 1999;49(443):477-482.

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