Kieran Walsh: Supporting shared decision making

Shared decision making is a process in which patients and healthcare professionals make decisions together. It is now widely accepted that all decisions related to an individual’s healthcare should be shared decisions. In fact, many people now argue that shared decision making doesn’t go far enough, and that we should be aiming for patient led decision making. Despite this, there continue to be barriers to shared decision making—some of these barriers are real, but some are based on myths. 

Légaré and Thompson-Leduc have done an excellent job of first outlining these myths and then debunking them in a 2014 paper. [1] Many of the myths reflect objections to shared decision making that I have heard through the years. Examples are that it is a fad; that patients don’t want it; that it puts too much pressure on patients; that it takes too much time; that we are already doing it; that we can get a tool to do it; that it will be too expensive; or that it is too mechanical and doesn’t take account of emotions. One of the interesting things about looking at this list is the fact that some of the myths are contradictory. For example, I have heard some people say that they don’t have time for shared decision making and then that they are doing it anyways. Or that it is too mechanical to be useful—but we can ask patients to use an online tool (which is unlikely to take account of their emotions). 

But a common theme that runs through many of the myths is that of time. For example, the reason why we develop tools that could do some or all of the shared decision making is to save time in the consultation. Also dealing with the emotions of shared decision making takes time; and time is money—leading to concerns about the cost of shared decision making. So we must take concerns about time seriously.  

Are healthcare professions right to be concerned that shared decision making will make clinical consultations run over? The evidence suggests that this issue may have been overplayed. Some research studies have shown that shared decision making prolongs the consultation; some that it shortens it; and some that it has no effect. [1] But if we accept that shared decision making is an integral part of the consultation, but also assume that it could make at least some consultations longer, then what can we realistically do to help? 

One option is delegating shared decision making to an online tool: but this is unlikely to result in real shared decision making. Another option is to create tools that can help shared decision making and that are quick and efficient. At BMJ Best Practice, we have concentrated on creating content that can inform decision making and that can be accessed by healthcare professionals quickly. This means improving search, and making the site navigable, and integrating the content into the clinical workflow. This should all help. However, a final alternative is to accept that high quality shared decision making takes more time and so make consultation times longer. If patients and their healthcare professionals come to better decisions as a result, it may be that time and costs may be saved further down the course of the patient’s illness. 

Kieran Walsh is clinical director of BMJ Learning and BMJ Best Practice. He is responsible for the editorial quality of both products. He has worked in the past as a hospital doctor—specialising in care of the elderly medicine and neurology.

Competing interests: KW works for BMJ Best Practice which produces a range of clinical decision support and learning resources for different types of healthcare professionals. 


1] Légaré FThompson-Leduc P. Twelve myths about shared decision making. Patient Educ Couns. 2014 Sep;96(3):281-6.