Shared Decision Making: An Interview with Mayo Clinic Professor of Medicine Victor Montori
November 3, 2019
Shared decision making, to be very conceptual, is essentially a fancy word to describe a conversation, and it is a conversation between at least two parties. One party is the clinician, traditionally considered the source of expertise about the decision, and the other party is the patient, traditionally considered the subject of the decision, the victim of the decision, if i may. This gets redesigned such that now the patient becomes an expert in their own life. Patients will tell you, “I don’t like to take pills”, “I’m not very good at taking pills”, or “when i take pills, my body doesn’t like them” and so I get a lot of side effects. They have expertise. I talk to my neighbour, my neighbour has had this. They have knowledge that they have. It could be correct or incorrect, but it’s knowledge that they have and they bring in. So instead of ignoring it, it is honouring it and it’s bringing into a conversation where they can share that, the clinicians can share their bit, and then they engage in a second phase after sharing that information where they deliberate, they consider the options and they sort of consider the pros and cons of each of the options. The pros and cons are considered in the context of the patient and in relation to what patient’s value and pursue. And from that process, the options set narrows down to perhaps the next best thing we can do together. One of the ways of describing this, is how I experienced when I was small child, and my grandfather was sick, and we were all in the hospital with the adults pacing around a set of closed doors, some of them were smoking at the time, they were smoking in the hospital. You know, pacing and pacing, and waiting, and then the doors would swing open and three or four clinicians would come out with their white coats and basically inform us we’ve made a decision, we’re going to operate. Right, so the process of information sharing with the family about the options, if it existed, was the minimal requirement for, essentially informed consent. In terms of deliberation, it all happened behind closed doors among the doctors. If you think of a single doctor it would all happen in the doctor’s head with no access, the patient would have no access to that process, and to understand what were the issues that were giving greater weight, and what were the issues that were giving less weight. No input at all. In our study, which now includes, you know, several thousands of instances of shared decision making used. What we’ve identified is that on average, shared decision making interventions extend the consultation by about 10%, so for a consultation in primary care of say twenty minutes, it is a two to three minute extension. Anything that enhances transparency and accountability in healthcare can begin to reduce the corruption of healthcare. Shared decision making is one strategy in which we make the options available, clear, in which we empower the patients to consider those options and to express their goals. I think clinicians have a moral obligation to actually do everything they can to provide that level of transparency to a decision making process and feel that they are accountable with patients for those outcomes. If you’re a young health professional and you want to participate in a patient revolution, you will see this system as it is, and you will be an agent of change. Shared decision making is one of the ways in which you manifest that spirit or that commitment to a patient revolution.