I was recently in Barcelona talking to a group of people interested in the taking of shared decisions (#decisionescompartidas) at a seminar organised by the Catalan Society for Health Management (SCGS) and the Agency for Health Quality and Assessment of Catalonia (AQuAS). My visit was the third stop on a trip which first took me to Poland and later The Netherlands. There is a very strong interest in the subject of shared decisions in all three countries and in all three there are efforts at different levels to promote this practice.
What motivates this interest is also something shared: the feeling that the involvement of patients in important decisions must inevitably reduce costs and improve clinical outcomes. It is also a general phenomenon that doctors feel cornered by this new expectation adding to their already existing agendas that compete for the meagre 7 minutes per patient.
In light of this reality, the promises to take shared decisions that better reflect the situation of a patient and how to deal with it, based on the informed participation of the patient, end up putting the onus on the patient of taking decisions by means of tools in web pages or on printed forms. But what about sharing the process of taking decisions? Corporate poetry, an academic dream.
Taking shared decisions requires patients and clinicians to work together so as to mutually agree on the best way to proceed in order to improve the patient’s situation. The outcome of this effort is a plan of care. To establish this plan it is important to understand what the situation of the patient is and what action is needed, as well as the options available to respond to the demands that the situation dictates in the best way.
The conclusion reached must make sense, intellectually, emotionally and practically. That is, the plan must reflect the best medical science, it has to be agreeable within the biological and biographical circumstances of the patient and be able to be implemented with the least possible inconvenience in the life of the patient. This work is not for the patient to do, nor the clinician, but for both. It is challenging and is based on a clinician-patient relationship, and it takes time.
Many clinicians tell me that they already take decisions together with their patients. This is not evident when we watch videos of clinical encounters in North America (15-30 minutes in length). In these, we see clinicians interrupting patients after less than 11 seconds from the time a patient begins talking, using humour to avoid emotional situations and offering recommendations before listening to the patient’s point of view.
Victor M.Montori in the Shared Decisions Conference (SCGS and AQuAS). Barcelona, 19 May 2017
The fact that patients want to participate or that they do in fact participate actively in the taking of decisions is not evident either and yet, patients report high levels of satisfaction in the way that decisions are taken. However, a critical look reveals that many decisions are taken without patients realising it, given that these decisions are disguised as the logical steps to follow in managing a problem rather than being opportunities for the patient to contribute in the process with their opinion, point of view, experience and knowledge.
The effort of converting the taking of shared decisions from what it is (a unicorn) to what it should be (something routine in the care of patients) is enormous and full of uncertainty. There is no country, in my opinion, nor any health system which is at the forefront on this subject. At the tail end, there are of course countless systems that are still hugely in debt with their populations for not yet having been able to guarantee universal access to health with minimum levels of quality and safety.
What those at the forefront need to do, in my opinion, has more to do with attitude and opportunity than with tools or incentive and training programmes. The latter must be there when attitude and opportunity appear.
In my visit to Barcelona I saw great willingness, but with noticeable limitations in attitude and opportunity. In attitude, as health professionals we need to value what patients know about their context, about their biology and biography and about the way in which they want to lead their lives.
We must acknowledge how essential it is that treatment plans make sense and that it is possible to implement them in the lives of patients, especially in the case of chronic patients. And we must be aware that practical guides and other management tools for management are useful to guide our treatment of “patients like these” but are not enough to determine the treatment for “this patient”.
But attitude is not enough. In addition, we need to work at creating opportunities for conversation between clinicians and patients and that these become therapeutic relationships. I believe that our intellect has evolved in the taking of decisions with others. In the same way that I believe in deliberative democracy for social problems, I believe in taking shared decisions for clinical problems.
Clinical problems are not simple (such as in the problem of baking biscuits, with a known recipe and ingredients and an expected result), they are not complicated problems (like flying a 747, with algorithms and feedback that lets one be confident of achieving the desired result) but they are complex problems (like raising a child, with known ingredients, without a recipe or algorithms and with sometimes unexpected results).
Complex problems cannot be solved by technical investments only. These are solved within human relations. Specific results cannot be expected, but one can respond to adverse situations with resilience. Without the fuel of opportunity for this, the flame of a favourable attitude in the taking of shared decisions will be extinguished in the end.
The taking of shared decisions needs human relations between clinician and patient to resolve the human problems of the patient with resilience. In turn, the solution of these problems requires decisions to be shared for the solution to make intellectual, emotional and practical sense in the life of the patient.
Besides attitude and opportunity, it is important to have interpersonal skills (or train up to acquire whatever is possible) so as to communicate with a patient with empathy, to understand their situation and to assess each reasonable option in the context of a conversation.
In this context, tools based on evidence designed specifically to support these conversations can be useful and can facilitate the efficient taking of shared decisions in any context, from emergencies to specialised care.
I am aware that many have found the motivation to participate in taking shared decisions thanks to training or the use of tools for taking shared decisions. This makes it important to understand what is necessary and where so that taking shared decisions becomes routine practice in the care of patients.
But what does all this effort achieve? Many colleagues say that the taking of shared decisions can improve clinical outcomes, the adherence to treatments, the use of services and the costs of care. Taking shared decisions might also help in preventing global warming.
My critical appraisal of the evidence available does not allow me to discern any of these benefits with a sufficient level of certainty. This forces us to consider why we must thus make the effort to create the conditions to be able to take shared decisions and to implement this as routine practice.
For me, as a clinician, the answer comes by means of understanding the aim of a treatment, of clinical care as well as by allowing each patient to fulfil their dreams with the least pathological interruption and the least therapeutic inconvenience possible. To achieve this, we need to design treatments that respond to a patient’s situation – seen in high definition – treatments that make sense for the patient, and a clinician cannot do this without the patient.