A meeting of two experts: How shared decision-making can support patient centred care

In 2014, the British Columbia Ministry of Health named patient centred care its number one priority under the Setting Priorities for the BC Health System strategic plan in an attempt to shift the culture of health care from being disease-centred and provider-focused. The goal was to give patients control over their health choices, support informed decision-making, and ensure the patient voice is “anchored in all behaviours and drives all activities of the health system.”

This sounds great in theory, but how do we put patient-centred care into practice? What strategies can support this ambitious goal of putting patients’ lived experience and expertise at the heart of health care?

Shared decision-making is a knowledge translation strategy that can help us, and the health system more broadly, do just that.

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What is shared decision-making?

Shared decision-making is a process or set of behaviours where health care providers and patients exchange information to understand the pros and cons of health care options, consider the patient’s values and preferences, and jointly decide on a strategy that incorporates both the clinical evidence and the patient’s preferences. The ideal result is a quality patient decision that is informed, consistent with personal values, and acted upon.

Consider it a “meeting of two experts” — the care provider offers their expert clinical knowledge while the patient and their family are experts on their lived experience with health and illness. By bringing together this expertise, patient values and evidence-based medicine, shared decision-making is considered “the pinnacle of good patient care,” and invaluable in a health system where there is often no single “right” decision.

Canadian researchers have dubbed shared decision-making a form of patient-oriented knowledge translation, and it also fits within the umbrella of integrated knowledge translation (iKT). In both iKT and shared decision-making, you create knowledge through the interweaving of practical wisdom, community perspectives, professional experience, and research evidence. This co-constructed knowledge aims to be more useful and useable for a patient considering a treatment decision, a health care provider supporting those decisions, or policy-makers allocating health care resources.

Table 1: Shared decision-making behaviours for health care providers
Essential elements Define and explain the problem
  Present options
  Discuss pros and cons (benefits/risks/costs)
  Discuss patient values and preferences
  Discuss the patient’s ability and self-efficacy
  Share knowledge and make recommendations
  Check and clarify patient’s understanding
  Make or explicitly defer a decision
  Arrange follow-up
Ideal elements Provide unbiased information
  Define roles (desire for involvement)
  Present evidence
  Reach mutual agreement

Shared decision-making behaviours adapted from Makoul and Clayman, 2006
 

What tools are available to support shared decision-making?

Shared decision-making requires effort and engagement from both the health care professional (table 1) and patient. But it isn’t always easy. Shared decision-making is a skill that requires training, time, and motivation to change. Support tools can help make the process smoother, whether they take the form of decision coaching scripts, index cards, interactive exercises, and patient decision aids (in video, paper, or web-format).

Patient decision aids are the most promising knowledge translation strategy and are supported by a vast body of evidence. The 2017 Cochrane systematic review of patient decision aids explored 105 randomized controlled trials involving 31,043 participants. When people use patient decision aids, they improve the quality of their decision-making, including:

  • Having knowledge of their options.
  • Feeling better informed and clear about what matters most to them.
  • Having accurate expectations of benefits and harms of options.
  • Participating more in decision-making.

In many cases, this results in patients choosing more conservative and non-invasive options, such as exercise and lifestyle changes over drugs or surgery. This is likely because patients are making a choice that matches their informed preferences, with a greater understanding of the potential risks and benefits.

But, having tools available does not mean that patients and health care providers will use them. Despite the benefits of strategies like patient decision aids, there is limited evidence that they change health care professionals’ behaviour and increase shared decision-maing. We need better research, and better reporting of research, to understand more about how to help and motivate healthcare professionals adopt practices to better involve their patients in the process of making decisions.
 

So how do we put shared decision-making into practice?

As always, context is key. By understanding the local context in which shared decision-making tools are used, we might get closer to creating tools that are both effective and more widely adopted.

I recently worked with Dartmouth College in New Hampshire, USA, to understand more about best strategies for implementing shared decision-making tools. We explored why some contraception clinics appear to implement shared decision-making and others have room for improvement.

This qualitative evaluation was part of the Right for Me randomized controlled trial. In the trial, 12 clinics implemented shared decision-making tools for contraceptive choices. Through interviews with front line care providers, I explored how staff implemented the tools, what did or didn’t work, and why.
 

Key learnings
 

  • Physical environment: We found the compatibility of the physical environment to be an important factor, with spaces, workflow, and even the location of power outlets all playing a role in whether a clinic found it easy to use shared decision-making tools. For example, in clinics that largely relied on paper over technology, staff struggled to remember to use iPad-based shared decision-making tools.
  • Knowledge and training: When the shared decision-making tools were introduced, we anticipated that health care providers would need to learn a new set of behaviours and provided them with a short webinar and resource. But we didn’t realize how important training would be for administrative staff who were responsible for giving tools to patients before their appointment. Looking outside the patient-provider duo allowed us to see how implementation of these tools is a system-wide effort.
  • Champions and motivators: In clinics where the shared decision-making tools were used with ease, self-appointed champions had given staff their roles and responsibilities. They checked in regularly with colleagues to motivate, support and encourage clinic staff to engage in shared decision-making.

Putting patient-centred care into practice won’t happen overnight. We can learn from exciting implementation stories from other jurisdictions, such as the MAGIC shared decision-making program in the UK and cutting edge studies from the Ottawa Hospital Research Institute.

In British Columbia, I am part of a broad team of researchers, care providers, and patients who are working alongside decision-makers to develop a shared decision-making training program for health care professionals. This includes making online patient decision aids available to the public to support choices around contraception, abortion and maternity care provision. We hope to have these tools ready for the public in 2019.

Throughout, qualitative research helps us to understand what works, for whom, and in what contexts to ensure patients and their health care providers are equipped and empowered to make patient centred care a reality.


Dr. Sarah Munro
Post-doctoral Fellow in the Preference Laboratory, Dartmouth College and Contraception Access Team, University of British Columbia, and a scientist in the Centre for Health Evaluation & Outcome Sciences.

Dr. Sarah Munro is a qualitative health services researcher whose focus is knowledge translation and implementation science. She completed her PhD in Interdisciplinary Studies at UBC where her research focused on the investigation of factors that influence implementation of shared decision-making interventions for patients and their care teams. She is currently a Scientist with the Centre for Health Evaluation & Outcomes Science (CHÉOS) and holds a joint post-doctoral fellowship with UBC Department of Family Practice and The Dartmouth Institute for Health Policy & Clinical Practice, USA. Her fellowship is supported by a Michael Smith Foundation for Health Research 2016 Research Trainee award.

The opinions expressed in this blog post are those of the author and do not necessarily reflect the views of the Michael Smith Foundation for Health Research.

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