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Clinicians and patients should work together to make decisions about which preventive services are most appropriate for individual patients, according to a new paper on the need for shared decisionmaking. In shared decisionmaking, the patient becomes an active partner with the clinician in clarifying acceptable medical options and choosing a preferred course of clinical care. The article was published by a working group of the U.S. Preventive Services Task Force, which is sponsored by the Agency for Healthcare Research and Quality.
As defined by the working group, shared decisionmaking is a process in which both the patient and clinician share information, participate in the decisionmaking process, and agree on a course of action. Shared decisionmaking also assumes that individual patients have weighed their own values about the potential benefits and harms of receiving or not receiving a medical service, and it allows patients to be as involved in the decisionmaking process as they wish to be. Shared decisionmaking offers a way to individualize preventive services recommendations according to patients' special needs and preferences when some patients may benefit from an intervention but others may not.
The working group's paper was written because Task Force recommendations are made for average-risk populations and are not designed to be a one-size-fits-all prescription for preventive care. Individuals may weigh the benefits and harms of various preventive services differently, and shared decisionmaking may be useful in a variety of situations, including the following:
- Shared decisionmaking helps patients and clinicians decide whether to use a preventive service that has a net benefit but also has potential for harm. An example is aspirin therapy, which helps prevent heart disease but can also cause stomach bleeding in some patients.
- Shared decisionmaking is valuable in deciding which of several equally acceptable screening options are appropriate for a patient. An example is colorectal cancer screening, in which five screening choices are available, including flexible sigmoidoscopy and colonoscopy.
- Shared decisionmaking is also valuable when new scientific evidence has caused a reversal of previous recommendations, such as the recent recommendation against use of hormone replacement therapy. In light of this, doctors and their patients may want to discuss whether patients should use hormone replacement therapy to relieve symptoms of menopause on a short-term basis.
Neither the working group nor the Task Force followed their customary process of conducting a systematic review of the scientific evidence, and no formal recommendation was made. The working group found few systematic studies that evaluated shared decisionmaking and noted that many areas require further research. The report does, however, include commentary on the current thinking and evidence regarding shared decisionmaking.
While there is no evidence that shared decisionmaking improves health outcomes, it is supported by a combination of ethical and practical arguments. Some patients may not want to participate in shared decisionmaking because they are confused about medical terminology and uncomfortable with taking an active role in making medical decisions. Other patients who don't read well or who have poor math skills may also hesitate to participate in shared decisionmaking. Encouragement by clinicians and their assistants is essential in helping these patients understand the value of participating in decisionmaking about their medical care.
For clinicians, shorter office visits, lack of reimbursement, and lack of interest and training in interviewing techniques may be barriers to shared decisionmaking. To address some of these concerns, the working group encourages clinicians and health plans to adopt a systematic approach that is likely to improve the quality of their interactions with patients. Decision aids such as pamphlets, computer programs, audio-guided workbooks, videotapes, videodiscs, decision boards, and Web-based tools that health plans and delivery systems share with patients and clinicians may be helpful, according to the working group.
Informed decisionmaking, in which an individual obtains and considers information about preventive services from any source (such as the Internet) without benefit of consultation with a clinician, is addressed in a separate paper by the Centers for Disease Control and Prevention's Task Force on Community Preventive Services. This paper appears in the same journal with the Task Force paper.
The working group paper on shared decisionmaking was developed in conjunction with members of CDC's Community Task Force. The authors of shared decisionmaking, researchers at RTI International and the University of North Carolina at Chapel Hill, and several members of the U.S. Preventive Services Task Force also met with other experts and clinicians to discuss the issue.
For more information, see "Shared decision-making about screening and chemoprevention: A suggested approach from the U.S. Preventive Services Task Force," by Stacey L. Sheridan, M.D., M.P.H., Russell P. Harris, M.D., M.P.H., Steven H. Woolf, M.D., M.P.H., and others in the January 2004 American Journal of Preventive Medicine 26(1), pp. 56-66. See also "Promoting informed decisions about cancer screening in communities and healthcare systems," by Briss, P., Rimer, B., Reilly, B., and others, in the same journal, pp. 67-80.
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