An integrative model of shared decision making in medical encounters

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Abstract

Objective

Given the fluidity with which the term shared decision making (SDM) is used in teaching, assessment and research, we conducted a focused and systematic review of articles that specifically address SDM to determine the range of conceptual definitions.

Methods

In April 2005, we ran a Pubmed (Medline) search to identify articles published through 31 December 2003 with the words shared decision making in the title or abstract. The search yielded 681 citations, 342 of which were about SDM in the context of physician–patient encounters and published in English. We read and reviewed the full text of all 342 articles, and got any non-redundant references to SDM, which yielded an additional 76 articles.

Results

Of the 418 articles examined, 161 (38.5%) had a conceptual definition of SDM. We identified 31 separate concepts used to explicate SDM, but only “patient values/preferences” (67.1%) and “options” (50.9%) appeared in more than half the 161 definitions. Relatively few articles explicitly recognized and integrated previous work.

Conclusion

Our review reveals that there is no shared definition of SDM. We propose a definition that integrates the extant literature base and outlines essential elements that must be present for patients and providers to engage in the process of SDM.

Practice implications

The integrative definition of SDM is intended to provide a useful foundation for describing and operationalizing SDM in further research.

Introduction

Decisions about tests, medications, procedures, referrals, or behaviors are an integral component of many medical encounters, and shared decision making (SDM) is frequently advocated in teaching and research about provider–patient interaction. However, the concept of SDM has been variably, and often loosely, defined. Some have acknowledged confusion surrounding the term [1], [2], [3], [4], but recognition of the problem has not yet generated a model of SDM that integrates previous work. The lack of synthesis is problematic for several reasons. First, inconsistent conceptual definitions lead to inconsistent measurement of SDM [1], [4], [5]. Second, the lack of a core definition of SDM complicates efforts to identify the relationships between SDM and outcome measures. Third, variable instantiations of SDM definitions make comparisons across studies difficult, if not impossible.

In terms of models of the provider–patient relationship, SDM is often positioned as a “middle ground” between paternalism (i.e., physicians make the decisions) and informed choice (i.e., patients make the decisions) [4], [6], [7], [8]. In that context, there is considerable overlap between SDM and constructs with similar connotations, such as informed decision making [9], concordance [10], [11], evidence-based patient choice [12], [13], enhanced autonomy [14], and mutual participation [14]. There is a duality to the way SDM has been positioned within the proliferation of definitions. For instance, it has been described as both a component of patient-centered care [15], [16] and an extension of patient-centered medicine [17], [18]. It has also been construed as the appropriate process for informed consent on one hand [19], and clearly distinguished from informed consent on the other [20], [21], [22], [23], [24], [25], [26].

Similarly, as noted by Charles et al. [1], models of SDM vary in the way they position the roles and responsibilities of each party. For example, Towle and Godolphin [27] suggested competencies for both physicians and patients, whereas others have placed more responsibility on the physician to elicit or respond to patients’ views [28]. There has also been increasing attention to patients’ preferred role in decision-making, with some asserting that for SDM to occur, patients must share equally in the decision-making process [4], [7], while others contend that patients’ role preferences be discussed and accepted [28].

Given the fluidity with which the term shared decision making is used, we conducted a focused and systematic review of articles that specifically address SDM to determine the range of conceptual definitions therein. We sought to identify the most frequently invoked elements, qualities, and citations used to define SDM, with the goal of integrating the extant literature base to offer a conceptually sound and clinically relevant model of SDM.

Section snippets

Methods

In April 2005, we conducted a Pubmed (Medline) search to identify articles published through 31 December 2003 with the words shared decision making in the title or abstract.

Results

Of the 418 articles examined, 161 (38.5%) had a conceptual definition of SDM; the primary search strategy yielded 144 (42.1% of 342) articles with conceptual definitions [1], [2], [3], [4], [5], [6], [7], [10], [11], [12], [13], [14], [15], [16], [17], [18], [21], [23], [24], [25], [26], [27], [28], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], [65], [66], [67], [68], [69], [70],

Discussion and conclusion

Our review reveals that, overall, there is no shared definition of shared decision making. This is clearly the case within the set of articles that included a conceptual definition: We identified 31 separate concepts used to explicate SDM, only two of which appeared in more than half of the conceptual definitions. The lack of coherence looms even larger because 60% of articles that purport to focus on SDM failed to include any conceptual definition at all. Equally troubling is the low frequency

Acknowledgements

We are grateful to Amanda Zick (Program in Communication and Medicine, Northwestern University Feinberg School of Medicine, Chicago) and Rachel Malis (Department of Communication Studies, Northwestern University, Evanston) for their invaluable help with reviewing abstracts and articles. Drs. Cathy Charles and Aviram Gafni (McMaster University, Ontario), Angela Coulter (Picker Institute Europe, Oxford), Glyn Elwyn and Adrian Edwards (Cardiff University, Cardiff), and Angela Towle and William

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