Democracy means involvement in decision making but it may not always lead to the best outcomes. With this simple analogy, Gerd Gigerenzer (Berlin), captured the potential hazards of clinical shared decision making in his keynote address to the 5th International Shared Decision Making Conference in Boston (June 14-17).
The concept of sharing decisions on treatment and screening with patients feels entirely appropriate but the implied benefit may be deceptive; measuring success depends on how we define desirable outcomes. Glyn Elwyn (Cardiff) emphasised that there was an ethical imperative for shared decision making in the context of patient autonomy. It undoubtedly improves patient involvement and improves satisfaction. But how do we measure the health benefit? Richard Thomson, an epidemiologist (Newcastle UK), raised difficult questions that may not have entirely pleased the audience.
He reflected on work on atrial fibrillation that was successful in involving patients and altered the decision making process. As a result, fewer patients opted for warfarin treatment. But, as he pointed out, this may lead to an increase in subsequent stroke rate. Patient informed choice, in this example, runs counter to evidence based guidance and creates a dissonance between personal and population health gain. He also used this example to ask if we need more generic measures of health, bearing in mind the well rehearsed WHO definition. Using this definition of health, shared decision making may lead to healthier patients but more illness.
It may also be difficult to win doctors over to this challenging paradigm and Wemke Veldhuijzen (Masstricht) showed that, given a choice, GPs will tend to select a strategy that meets the perceived preference and needs of the patient rather than share the decision making. It takes more time in the consultation, and if GPs do chose to work in this way, we need to appreciate that there will be a trade off with other activities.
More sophisticated decision support systems should help, but Gerd Gigerenzer showed evidence that sometimes doctors make better decisions with less information; a more sophisticated prognostic model may have an optimal fit but less predictive value. He even ventured to suggest that heuristic strategies may be better than optimisation. Loosely translated this means following your gut feeling.
On the day following Barack Obama’s address to the American Medical Association in Chicago, it was fascinating to hear Susan Dentzer , editor in chief of Health Affairs, speak about the proposed changes in American health care. Equity is an important concept in the UK but there is considerable resistance in the US to socialised medicine. It was no surprise therefore to hear that Obama was both applauded and jeered at the AMA. Many doctors feel that health care reform is long overdue but others believe there should be no restriction on individual choice on treatment.
There is considerable resistance to comparative effectiveness research and a feeling that US doctors would resist a NICE type structure that implies rationing, non personal care and a threat to doctor autonomy. The Obama administration is keen to introduce major change and, in particular, a government-sponsored insurance scheme alongside private insurance to help protect the almost 50 million uninsured Americans. The details have not yet been decided but you can follow the developments on healthreform.gov. Winning over the doctors is just one battle in a country founded on the principles of individual choice. Many argue that they should not have to pay for someone else’s health care.
Shared decision making is not for everyone. Susan Dentzer brought a smile to the audience when she recalled Obama’s description of his relationship with his own physician: “ and I include myself, Michelle, and our kids in this — we just do what you tell us to do.” I smiled too but, was reminded of my flight to Boston, when the pilot of my plane announced a long delay in take off because there was a storm on the flight path. I was happy not to share in that decision either.
Domhnall MacAuley is primary care editor, BMJ