“There’s nothing shared about a patient’s choices” – Dr Andrew McCulloch on Shared Decision Making
When I think of the word “shared” I instantly envision balance and more specifically an equal balance of whatever is being “shared”. Yet in the case of “shared decision making” in healthcare this is not only not a true reflection of the doctor / patient relationship, but a misleading one.
The term implies that doctors and patients have equal status in the decision making process, when more often than not, it’s usually patients’ who make their own health care choices – not them and their doctors together.
But in truth, while doctors are ultimately accountable for the implementation and outcome of patient treatments – with the exception of the Mental Health Act, or other rare occasions where a patient’s competency is in question, they do not have the power to force them to make any specific healthcare decisions. Clinicians can offer advice as clinical experts but whether or not the patient chooses to follow that advice is up to them. “Shared decision making” is therefore not a reflection of reality, the process of deciding on a care pathway is much more complex than the terminology suggests.
Perhaps, what is most important is transparency. It’s not so much about clinicians sharing the decision making process with patients, more them clearly explaining the reality of a patient’s situation to them from every angle so that they are aware of every option available, and able therefore able to make informed decisions, themselves.
Every patient is a person, who has their own set of unique health decisions that make up their personal care pathway. “Shared decision making” to my mind implies a simple process of collectively making a single decision about one isolated incident. One where doctors tick “the shared decision making” box, and that’s the end of it. The reality is as we all know far more complex, and a checked box on a form just doesn’t do the process or service justice. It comprises of a convoluted series of events that require significant consideration and education to make them.
Education. An imperative for both clinicians and patients alike, and the only way to truly embed increased transparency from the top tiers of the NHS through to frontline staff. While it is true that patients need to be educated about their condition and treatment options, in order for this process to be truly successful clinicians need to be educated, not just medically but emotionally. It has been said that a key tool in a Doctor’s kit is bedside manner, and that is especially true when it comes to care decisions. No two patient experiences are the same, and while they will all require a level of education around their care options and decisions, every individual will need a different approach and degree of support. For example elderly patients often want to be guided through their medical decisions, trusting in their care giver implicitly. While other groups, like young professionals, may have more confidence in their own decision making capability. And, although they both expect and appreciate a doctor’s guidance, they may prefer to take charge of their own health choices. Whereas for others, the preferred approach falls somewhere between the two.
Therefore doctors not only need clinical know-how to deliver a quality patient experience, but the soft skills that enable them to listen to and support people as they make care decisions, on their terms – in their own way.
Similarly for the process to be as “shared” and balanced as the term suggests, it requires the doctors themselves to do some reflection and not allow preconceptions to affect clinical judgement. It is something that we all prefer to ignore and deny but preconceptions and immediate impressions affect our dealings with others, including doctors with patients. Though of course not all clinicians are guilty of this, having experienced it myself, I know first-hand that some are.
For the bulk of my adult life I have been in the rare, and, I’m aware, privileged position that my job title, (first as a civil servant in the health & policy sector and then as CEO of a prominent healthcare charity), has to a degree informed clinicians opinion of me. And that therefore they have provided a level of detail about my care that is perhaps not reflective of what they would give to all their patients. As a young man however, I can remember vividly being patronised, by a particular doctor, when I asked a question about a specific medication. The question was quickly dismissed and in turn so was I. Ironically, at the time I was working as a lab technician at the Welcome Trust – and was likely more informed about this particular medication than he was. Yet my youth and perhaps the meek way I presented myself to him, had allowed him to form a perception of me as a patient, that allowed him to dismiss any concern or question I had, that he did not feel appropriate.
Whatever you want to call it, it comes back to one fundamental thing; person and family-centred care – the only real way to deliver a quality care experience. Therefore for me, the real value of the initiative lies not only in supporting patients through their care decisions but providing the tools and training that allow clinicians to give patients the bespoke care experiences that they need. For that to happen all the experience elements need to be considered and come together, empowering both patients and staff to fulfil their roles and make the process work.
Perhaps all of the above are embodied in the principle of “shared decision making”, but if they are they are not explicitly laid out, and for the initiative to have the desired impact, supporting the elevation of care quality to optimum levels, they need to be.
On the positive side the developing narrative, and open dialogue around the subject is a big step forward for person and family-centred care, and the growing body of good quality research on the subject is invaluable.However for progress and improvement to be made continuously, we must be careful not to allow the subject to become too misleading. If nothing else, it never hurts to remember a concept’s limitations and think of ways for it to realise its true potential in the future.