The seventh International Shared Decision Making (ISDM) conference, sponsored by the BMJ, took place in Lima, Peru, over the last three days. It was organised by Victor Montori, a charismatic global proponent of patient centred care, who is a native of Lima and professor at the Mayo Clinic. The motto he chose was “pacientes @ the centre of healthcare,” emphasising the Hispanic location, internationalism (with centre spelt the British way), and the need to recover respect for the patient on a global scale.

“This is a group of people committed to study a unicorn,” said Montori at one point. He was referring to the rarity of finding clinicians and patients actually discussing treatment options on an equal footing. The unicorn was just one of many metaphors which kept recurring through a lively and optimistic conference. The metaphor that Glyn Elwyn used in his opening talk was of nuts and bolts and power tools. Helping patients and clinicians to feel comfortable with sharing decisions requires simple decision aids which can be used in real time. The Option Grids he pioneered are one example, and he demonstrated how power can be exchanged in the clinical encounter simply by handing over a pen to the patient together with a single sheet of paper comparing their basic options.

A flywheel gradually gaining momentum was another metaphor. Progress in SDM can seem painfully slow and effortful, but it is being achieved in a multitude of ways. A collaborative based in Ottawa is assessing the quality of several hundred decision aids using the updated score called IPDAS; the latest Cochrane review of trials using decision aids is among the top three most accessed reviews on the Cochrane site. Gordon Guyatt, often called the father of evidence based medicine (EBM), discussed how EBM needs to inform shared decision making (SDM) and how evidence synthesis needs to be tailored to support SDM.

Ronald Epstein from the University of Rochester gave an outstanding account of the ways in which decisions can be shared with patients who have life-limiting conditions. This involves much more than a simple process of information exchange: it is a complex endeavour to achieve a state of shared thinking, a constantly developing process of “muddling through,” where goals can change and evidence is rarely sufficient in itself to guide choices.

Gary Schwitzer, doyen of US medical journalists, used a military metaphor: getting reliable information to patients so that they can make sound choices is a pitched battle with the vested interests which distort the evidence in favour of what they are trying to sell. A rich mix of workshops and presentations demonstrated how diverse and energetic the armies of SDM are becoming. In the breaks there was a constant buzz of networking and the sound of people sharing ideas, experiences, and jokes. In a magic moment, Jennifer Kryworuchko, who helped to organise the event, picked up on Victor Montori’s metaphor of shared decision making as a unicorn: she told the audience that it needs to be shining unicorn, a new form of life which everybody will wish to welcome and to ride on.