Involving patients in medical decisions: how can physicians do better?

Learning points from paper

Physicians have not generally embraced the concept of shared decision making in day-to-day office practice. (See: Braddock CH III, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed decision making in outpatient practice: time to get back to basics. JAMA.1999;282:2313-2320.)
Time is certainly a major issue in trying to incorporate shared decision making into office practice. Trying to explain, in a balanced way, the complex issues behind controversies such as whether to perform a PSA test or prescribe estrogen replacement therapy cannot be done quickly.
For decisions that must be faced routinely in office practice, educational materials such as pamphlets, videotapes, or even interactive videodiscs may be helpful for communicating basic information about a decision and the possible outcomes of different management options, so that clinicians’ limited time can be spent not on basic education, but on tailoring the management strategy to the patient’s preferences.
For example, a 20-minute videotape on the PSA decision has not only improved patient knowledge about the PSA test, but also significantly reduced rates of PSA testing in 2 separate randomized trials. (See: Flood AB, Wennberg JE, Nease RF, et al. The importance of patient preference in the decision to screen for prostate cancer. J Gen Intern Med. 1996;11:342-349; Volk RJ, Cass AR, Spann SJ. A randomized controlled trial of shared decision making for prostate cancer screening. Arch Fam Med. 1999;8:333-340.)
Patients want to participate in decision-making tasks (i.e. choosing from a number of reasonable alternatives, where the optimal choice will be preference-driven), but not problem-solving ones (i.e. getting to the one
right decision in a particular situation, a solution unaffected by patient preferences). See: Deber RB, Kraetschmer N, Irvine J. What role do patients wish to play in treatment decision-making? Arch Intern Med. 1996;156:1414-1420.