Patients should be involved in making decisions about their health care. The ethical imperative of autonomy is reflected in legal trends that require a high standard of disclosure for informed consent, amounting to a principle of informed choice.1–3 Outcomes of care and adherence to treatment regimens improve when patients are more involved.4,5 Consumerism is part of the social spirit, and governments exhort citizens to take more responsibility.
Models of doctor-patient encounters that result in increased involvement of patients and that are informed by good evidence have been termed, for example, “informed patient choice”6–8 but do not describe the interactive process clearly. We use the term informed shared decision making to describe decisions that are shared by doctor and patient and informed by best evidence, not only about risks and benefits but also patient specific characteristics and values. It occurs in a partnership that rests on explicitly acknowledged rights and duties and an expectation of benefit to both.
- Competencies for the practice of informed shared decision making by physicians and patients are proposed
- The competencies are a framework for teaching, learning, practice, and research
- Challenges to putting informed shared decision making into practice are perceived lack of time, physicians’ predisposition and skill, and patients’ inexperience with making decisions about treatment
We propose that a demonstrated capacity to engage in informed shared decision making is characterised by a set of necessary and sufficient competencies. By competencies we mean the knowledge, skills, and abilities that represent the instructional intents of a programme, stated as specific goals.9 They are a framework for teaching, learning, practice, and investigation of what should be a coherent process and an accomplishment of any doctor-patient encounter in which a substantive decision is made about treatment or investigation for which reasonable choices exist. They are mainly related to communications skills, but at a higher level than those typically taught in medical schools and continuing medical education, where the emphasis tends to be on obtaining information from patients (diagnostics), breaking bad news, and health promotion. We present them with an intent of parsimony and coherence. The sequence is not intended to be prescriptive, nor do they describe verbal phrases or a check list of behaviours. The time and attention paid to the separate elements will vary with circumstances; they may occur over several encounters and will probably be iterative.
It seems logical that if informed shared decision making takes place in partnership then patients should bring certain abilities to the encounter. If the sole responsibility for informed shared decision making rests with physicians then we tend to perpetuate the paternalistic “doctor knows best” relationship. Others (such as a doctor’s nurse or receptionist and a patient’s spouse or parent) may also make important contributions to informed shared decision making. Although our work has mainly focused on the development of competencies for physicians, we have developed a preliminary set of complementary competencies for patients.