Incorporating Shared Decision Making in Your Practice

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Incorporating Shared Decision Making in Your Practice
Incorporating Shared Decision Making in Your Practice

With the explosion of health information that is available these days, patients are increasingly wanting a stronger role in their health care decisions – perhaps especially so around psychiatric medications.

The traditional “doctor knows best” clinical appointment is increasingly being supplanted by a more patient-centered process. This is not just a simple preference. Clinical decisions made in partnership between informed patients and treating providers are often the most effective. 

The process whereby a patient and provider come together as partners in making care decisions is referred to as Shared Decision Making (SDM). In a clinical appointment that incorporates SDM, the focus is on the sharing of information, building consensus, and making an agreement around a decision.1

SDM differs from the “traditional” appointment that relies on informed consent – where patients are informed about a care recommendation, but often have little input into the actual decision itself.


In SDM discussions, the patient provides their personal experience and treatment preferences, and the provider offers clinical observations and clinical evidence. Both players serve as experts in their respective subject areas.

In this way, SDM can be thought of as the “sweet spot” for incorporating both evidence-based and person-centered care information.   

For instance, two different antidepressants being considered for a patient's goal of feeling less depressed might be expected to have similar benefits, but differ in their secondary sedation and weight gain properties. With the SDM model, the patient and provider both voice their perspectives about these concerns before working toward a consensus as to the right choice.

The principles of SDM are especially important in scenarios like this, in which relatively equivalent treatment options exist. This is often the case in psychiatric medication recommendations where “relative equivalency” is a common concept among medication options.

When providers first start incorporating SDM into their practice, they may be surprised to find that  patient expectations from medication treatment frequently differ from their own, and are oftentimes unrealistic. 

SDM practices encourage practitioners to identify the patient's medication goals early in the psychiatric medication discussion.2 Improved alignment between the patient and provider in expected outcomes is one of the primary benefits of SDM. Other benefits include decisions that are more likely to be well received, to improve the clinical relationship, and to promote patient empowerment.3

So how does one incorporate SDM methods into clinical practice?  Generally, the efforts fall into three areas: Practice Change, Decision Aids, and Peer Services.

The first element involves changing how we provide services. The concept itself is not difficult. For instance, Elwyn and Frosch3 have described a nice three-step method for performing shared decision making. Those three steps are:

  • Introducing the patient/consumer to the idea of choice
  • Describing the available treatment options
  • Assisting the client in exploring preferences and making decisions

This stepwise approach may sound relatively simple, but practice change, especially for teams or whole organizations, usually takes thoughtful, deliberate planning and ongoing support. 

The impact on all stakeholders should be considered – especially the impact on the patient, who may perceive SDM methods, however welcome, as new and unfamiliar. Fortunately, there is an increasing amount of support materials available to clinicians and program planners who want to learn more.4,5 

The second strategy for implementing SDM is the provision of patient support resources – also known as decision aids. Many decision aids are now widely available electronically or online.  Examples of such tools include patient medication lists, mood calendars, “questions for my doctor” lists, care planning tools, and patient education materials. 

These materials can really support the patient's efforts, serving as a sort of “homework” between clinical visits. The use of patient self-rating scales can be particularly useful. Not only do they assist the patient in tracking their own symptoms and care, but they also can be a nice source of information for the clinician when brought to the appointment itself.  

Finally, peer services and supports can be another important element of a SDM program. Peer resources can be invaluable in helping patients contextualize their treatment choices, destigmatize their symptoms, and share real-life stories of how medications can be helpful.

Though not all of the elements of SDM – practice change, decision supports, and peer services – can be applied in all settings, I have found you can apply many of them in most circumstances with good effect.

By implementing SDM practices, psychiatric medication providers have an excellent opportunity to improve clinical practice in ways that are meaningful to patients. This is more rewarding for clinicians in our efforts to be compassionate and effective clinical providers.

Marc Avery, MD, is a Clinical Associate Professor and Associate Director for Clinical Services at the AIMS Center, at the University of Washington School of Medicine in Seattle. He serves on the Psychiatry Advisor editorial board.

References



  1. 1.Charles C, Gafni A, Whelan T. “Shared Decision-Making In The Medical Encounter: What Does It Mean? (or it takes two to tango).” Soc Sci Med. 1997; 44(5): 681–92.,/li>
  2. 2.Deegan PE, Drake RE. “Shared Decision Making And Medication Man­agement In The Recovery Process.” Psychiatric Services. 2006;57(11): 1636-1639.
  3. 3.Elwyn, G, D, Frosch et. Al.; Shared Decision Making: A Model for Clinical Practice.  J Gen Intern Med. Oct 2012; 27(10): 1361–1367.
  4. 4.SAMHSA: Shared Decision –Making in Mental Health Care, HHS Publication No. SMA09-4371, 2011. Available at: http://store.samhsa.gov/shin/content/SMA09-4371/SMA09-4371.pdf.
  5. 5.CalMend Guide for Person Centered Mental Health Services and Supports: Transforming Care to Promote Wellness and Recovery. Available at: http://www.dhcs.ca.gov/provgovpart/Documents/CalMEND/CalMENDGuide103108.pdf
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