“Let Me Show You How I Think About This Problem…” : Impactful Nuances of Shared Medical Decision-Making

Abstract

Shared decision-making is a key component of patient-centered care. In this clinical vignette, we illustrate the value of bringing patients into the clinical thought process as part of shared decision-making.

Cancer has occupied a foreboding space in my (A.R.) mom's imagination for most of her life—her sister and father both died from some form of cancer. When an elective hysterectomy was aborted following an incidental finding of peritoneal nodules, my mom had her worst fears realized. Biopsies confirmed malignant peritoneal mesothelioma.

She and my dad started her care back home with visits to a surgical oncologist at our local hospital. There, the oncologist invited her perspective and concerns but went on to provide biomedical statements rather than accessible guidance on care. Their questions were met with similar responses. My parents spent hours after each appointment retracing the discussions, trying to decode the doctor's meaning when he said “lesion” instead of “tumor,” then switched to “nodule.” Was one worse than the other? Without any knowledge of cancer biology, they relied on the doctor's body language and tone with each to try and understand. They were left with more questions than answers and decided to pursue a second opinion.

This time the conversations with her physicians went differently. Rather than a recitation of facts and opinions, my mom's doctors listened to her perspective and concerns about treatment and followed them up with analogies that communicated their shared values regarding surgical management; aggressive treatment without first understanding the full extent of her disease was, for example, akin to mistakenly filling up a plate at the beginning of a buffet. The value of pre- and postoperative imaging was explained as accompanying biopsy findings to illustrate the complete picture of her disease. Evidence of improved outcomes with CRS plus HIPEC versus CRS alone were shared. With statements like, “when we think about peritoneal mesothelioma…,” “what I am looking for when I review your CT…,” and “this concerns me because…,” my parents were invited into the clinical decision-making process, and it finally gave them the confidence to proceed with treatment.

Shared decision-making (SDM) has increasingly been proposed as a valuable model for medical decision-making in clinical encounter (1–3). Although there remains no universally accepted definition of SDM (4,5), one of its earliest mentions in the 1980s outlined SDM as a model for patient-centered care (6). Many current models consider SDM an inclusive, collaborative approach to medical decision-making wherein patients and their physicians function as full and equal partners in contributing to decisions about treatment and care. The role of the physician includes, but is not limited to, eliciting a patient's values regarding treatment and reviewing the potential harms and benefits of therapeutic options, as well as sharing relevant data, in order to facilitate discussion on informed consent and cooperatively select an appropriate plan of care (7,8). As such, the patient assumes an active role in their own medical care, as opposed to the passive role ascribed to patients by solely physician-driven decision-making in the medical encounter (3). In practice, however, SDM may often involve a mixture of patient and physician-driven interaction. To this end, the SDM process requires flexibility and adaptive decision-making from providers, in addition to the tolerance of a patient's ultimate decision. SDM continues to be adopted across the US health care system (4), and is practiced across a wide range of clinical specialties and settings, such as surgical consultation and palliative care, among others (9,10).

The available literature on SDM is ripe with methodology and often contains examples of specific phrasing that clinicians can use to engage effectively with patients in this process (2,9). In particular, word choices to help open a discussion of options and their differences, check patients’ current knowledge and elicit preferences can be instructive. Decision support tools may also assist these efforts. However, despite its emphasis on collaborative medical decision-making, SDM as it is often conceptualized may not provide best communication practices for demonstrating clinical reasoning to patients.

In our clinical vignette, the element of the medical encounter that stood out as most impactful was the second physician's effort to invite the patient and family into their clinical thought process. As medical knowledge has vastly expanded, choices have multiplied and decision-making has become more complex. Many patients, as in our example, may be overwhelmed by voluminous data and terminology even when it is plainly presented; some may find it quite helpful to observe the physician's analytic process, wherein phrases like “Let me show you how we think about…” and “What I am looking for when…” are grounding and may provide clarity. These statements, followed by demonstrated thought processes, may also prove helpful for patients who have done a lot of homework before their visit, which is ever more common in our current era of easy access to medical information, open notes, and medical chart transparency. Just as in the adage “a picture is worth a thousand words,” bearing witness to a complex task can be more illustrative than studying each individual component. SDM works best when it includes thoughtful communication, adapted to the unique needs of each individual patient.