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the art of medicine. Actively soliciting and incorporating the values and preferences of patients forms part of this. The excellent doctor seeks to craft and fashion scientific knowledge into a management plan that accords with the world and the experience of the patient. An appropriate clinical decision
therefore encompasses: ■■ the best available evidence ■■ compatibility with the patient’s values and preferences
■■ consideration of all available options ■■ consideration of practicality and achievability
■■ satisfaction for all parties ■■ achievement of the best
outcome for the patient. The climate in which doctors and patients communicate is also critical in influencing decision-making. This climate influences how doctors present information and the way in which patients interpret that information. Research demonstrates that the perception of risk by patients is related to the way information is presented to them.3
For example, patients can
make completely different choices from looking at the same data depending on the way supposedly “hard” statistics are communicated. Factors influencing the climate of the conversation between doctor and patient include:
Emotional state Consider the influence on
decision-making when: ■■ A patient is feeling confused, angry or even bored and disinterested.
■■ A doctor is feeling tired, distracted or exceptionally happy.
Underlying preferences Does the patient or the doctor think in terms of “natural progression” and “artful watchful-waiting” over “invasive”, “risky” intervention? Or does the doctor or the patient have a tendency towards thinking about active, decisive action over doing nothing and failing to act? Does the patient prefer graphs, numbers, written or verbal information? Does this accord with the doctor’s preferences?
External pressures
How many other patients does the doctor have waiting and how does this influence his/her communication of risks and benefits? What else is going on in a patient’s life that influences
his or her need for intervention vs conservative management?
Capacity to consider alternative views
How “right” do we think we are? How open are we to the possibility of a variety of views? Do we think in terms of black/white or can we see the grey? All human beings think and make judgments via a series of these and other mental filters. Shared decision-making entails doctors remaining mindful of the climate of the conversation and seeking to actively understand and flex their own communication style to meet the needs of patients.
THE IMPORTANCE OF PATIENT AUTONOMY Every country where MPS provides service to members has seen regulatory, professional and disciplinary bodies increasingly highlight the importance of respecting patient autonomy. Guidance from such organisations includes a reminder to doctors of their ethical duty to respect autonomy, as well as the importance of suggesting options to the patient and facilitating agreement on a management plan. Of course, people have a wide variety of preferences and all doctors will have experienced situations where the patient insists on being actively involved, in contrast to others where the patient insists on relying on the doctor’s opinion. Interestingly, despite these
preferences, patients tend to place more value on the process of involvement in shared decision- making, rather than on who was perceived as actually making the decision.4,5
It appears that most
patients prefer an involvement in a two-way conversation where options are discussed and the decision around a management plan is shared.
SHARED DECISION-MAKING: A FIVE-STEP PROCESS As a practical way of promoting such a two-way conversation, MPS advocates a five-step process for shared decision-making: 1. Building trust and rapport 2. Exchanging knowledge 3. Exchanging opinions and concerns 4. Discussing options 5. Achieving outcomes.
Through using this approach in situations where an adverse outcome does subsequently arise, both patients and doctors are more likely to recall the comprehensive process that was followed in reaching a best possible decision. From 2012, MPS members will be able to attend the Mastering Shared Decision Making workshop to learn in more detail how to reduce risk through negotiating and agreeing management plans with their patients. At the workshop, participants can learn more
The climate in which doctors and patients communicate is also critical in influencing decision-making. This climate influences how doctors present information and the way in which patients interpret that information
about the reasons why “just getting the consent form signed” is unlikely to meet the increasing expectations on members to actively respect patient autonomy. The workshop is designed for doctors from all clinical backgrounds involved in initiating patient treatment plans and outlines an effective approach to facilitating these important conversations. Through adopting a shared decision-making approach, doctors can enhance their skill in practising the art of medicine, demonstrate their respect for patient autonomy and reduce the risk of patient dissatisfaction that leads to medicolegal risk.
REFERENCES
1. Government of Western Australia Department of Health, Delivering Saver Healthcare in Western Australia: WA Sentinel Event Report 2007-2008 p11-13 (2008).
2. Degner LF et al, Information Needs and Decisional Preferences in Women with Breast Cancer, JAMA 277(18): p1485-92 (1997).
3. Gurm HS and Litaker DG, Framing Procedural Risks to Patients: is 99% Safe the same as a Risk of 1 in 100? Acad Med 75(8): p840-2 (2000).
4. Edwards A and Elwyn G, Inside the Black Box of Shared Decision-making: Distinguishing between the Process of Involvement and who makes the Decision, Health Expect 9(4): p307-20 (2006).
5. Longo MF et al, Involving Patients in Primary Care Consultations: Assessing Preferences using Discrete Choice Experiments, Br J Gen Pract 56(522): p35-42 (2006)
ARTICLE
ASIA CASEBOOK | VOLUME 19 | ISSUE 3 | SEPTEMBER 2011
www.medicalprotection.org
VALENTIN CASARSA/
ISTOCKPHOTO.COM
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