“Nothing about me without me”…. Picker Institute
Every day as a busy clinician you make countless decisions regarding patient care. This includes decisions about diagnostic options, treatments, dispositions of patients, follow up and management of your patients. Some decisions have clear and compelling evidence, and few alternative paths. For example, a fractured hip needs to be repaired or acute bacterial meningitis needs antibiotics. Therapeutic action supersedes rigorous patient discussion (but does not completely replace it). However, for many medical decisions, the evidence is not compelling or there are multiple similar options. In this case, truly patient centered care asks for thorough discussion and consideration of patient’s preferences and values in making the decision. For instance, which option to choose for early stage breast cancer has quite different effect on the patient’s appearance, survival potential, and cost? This is what is called by the Dartmouth Atlas, “preference sensitive care”. In these cases, engagement with the patient in making the decision in order to fully understand and take into account their preferences and values is of paramount importance. A Cochrane Review of shared decision making found that in 86 trials that were examined, there was a consistent improvement in patient knowledge, more accurate risk perceptions, greater number of decisions that were consistent with the patient’s values, reduced level of internal decisional conflict, and fewer patients remaining undecided or passive.
The Agency for Healthcare Research and Quality (AHRQ) has developed an approach to assist physicians and other caregivers in taking a systematic approach to Shared Decision Making. This approach called SHARE 1 provides a five step process that includes:
Step 1: Seek your patient’s participation. Communicate that a choice exists and invite your patient to be involved in decisions
Step 2: Help your patient explore and compare treatment options. Discuss the benefits and harms of each option
Step 3: Assess your patient’s values and preferences. Ask open and non-judgmental questions.
Step 4: Reach a decision with your patient. Decide on best option and arrange follow up
Step 5: Evaluate your patient’s decision. Revisit the decision and monitor its implementation.
AHRQ provides shared decision making tools for both clinicians and for patients. These include:
Beside AHRQ, a number of other organizations offer patient decision aids for shared decision making which include:
A full inventory of resources of patient decision aids is available at:
In coming blogs, we will dive more deeply into the steps outlined above, and explore communication with patients and overcoming health literacy barriers, and heightening cultural awareness in your practice.
Partnership HealthPlan of California is eager to assist network practices and clinicians at becoming more skillful in shared decision making, and will be offering onsite training. Stay tuned!
Submitted by Scott Endsley MD, Associate Medical Director, Quality