John W. Williams Jr., MD
Professor of Medicine and Psychiatry, Duke University
As a patient, would you want your physician making healthcare decisions on your behalf without any regard for your personal preferences, values, or needs? If you’re like most people, you’d prefer to be involved in choosing the care that’s right for you. After all, it’s your body, your mind, your financial resources, and your life.
Shared decision making, or SDM, is a process through which you and your healthcare provider make decisions together, as partners. It’s a common sense concept: you discuss the things that matter to you, then your doctor provides information and works with you to choose the best treatment for you.
This idea is particularly important when it comes to mental health care. Common conditions like depression and anxiety can be treated in many ways, but patients are often unaware of different options. SDM educates and empowers patients to make a choice that best suits them.
As our healthcare system grows and changes, SDM is gaining ground. As current or future patients, understanding this process and actively asking for this kind of personal attention from your healthcare providers will allow you to be more engaged and invested in your healthcare.
Why shared decision making matters
As a primary care physician and professor of medicine at Duke University Medical Center, I’ve come to understand the power and importance of patients’ voices. When you actively express your values, desires, and concerns to your physician, it helps your physician understand your priorities. Patients get better care and doctors get better at their jobs. Everyone wins.
Most patients are looking for this kind of care. Over 90 percent of patients seen in primary care practice say they want to either make healthcare decisions themselves or work with their care team to make a choice, versus having a decision made for them.
Researchers have also found that SDM is beneficial for patients. It improves their experience, knowledge, and ability to make decisions. Patients using this process are more confident and have less decisional regret. It represents the future—patient-centric care—in which doctors are respectful of and responsive to the preferences, needs, and values of each patient as an individual.
Patients know their own needs
Doctors may know a lot about medicine but, as the patient, you’re the expert on your personal values and needs. Your input matters most when it comes to deciding on how you should be treated.
If you and your physician are discussing treatment options for depression or another mental health issue, he or she should be asking you a lot of questions. Are you okay with taking medication, or would you prefer to avoid medicines if possible? Are you concerned about specific side effects? Are you willing to change your daily routine or lifestyle? What really matters to YOU when it comes to getting better? These are crucial questions and only you can answer them.
If your physician doesn’t know these important details about you, he or she is likely to prescribe a standard treatment that doesn’t take your individual situation into account. In current practice, many primary care physicians do not consider patient preferences when making treatment recommendations for depression. As a result, there may be a mismatch between the treatment preferred (e.g., psychotherapy) and the treatment prescribed (e.g., an antidepressant).
When should you expect shared decision making?
As a patient, it’s not realistic to expect SDM to come into play in every medical situation. For example, if you come to the emergency department in the throes of a heart attack, the doctor on duty will probably give you an aspirin to chew. The treatment risk from the aspirin is low, the potential benefits are high, the time window to take action is narrow, and almost all informed patients would want the aspirin. In that case, discussing your personal needs and values isn’t really necessary.
If you’re a patient talking to your doctor about Major Depressive Disorder, however, there are several possible care options: web-based Cognitive Behavioral Therapy, exercise-based therapy, talk therapy, medication, etc. Each might potentially be effective alone or in combination.
In scenarios like this where there are many treatment choices and more time to consider these options, you deserve to have a healthcare provider who will walk you through the decision making process so you can make a choice that aligns with your lifestyle, values, and wishes.
How patients can make shared decision making happen
If you’re a patient and your doctor hasn’t engaged you in SDM, bring it up. Tell him or her that you’d like to be involved in understanding what your options are for making important healthcare decisions together. There are many tools doctors can use to help you through this process. These “decision aids,” as they’re often called, come in a variety of formats including half-page documents, one-page summary forms, booklets, etc., and are delivered on the web, on DVDs, and on tablets. For those available online, you can study them at home. One excellent tool that can be helpful for both you and your doctor is the Mayo Clinic Shared Decision Making National Resource Center. In my teaching practice, the Statin Choice Decision Aid has been popular with physician trainees and patients.
If a physician says no to your request for SDM, consider how well your needs are being met overall before making any decision to change physicians. Ask why she or he is opposed to including you in the process. The good news is that more and more doctors are learning about this process and putting it into practice.
The future is patient-centric care
Unfortunately, SDM still isn’t the norm. Things are improving, but there are many challenges ahead. The Comprehensive Primary Care (CPC) initiative—a multi-payer quality improvement initiative designed to deliver comprehensive primary care—offers bigger payments for doctors who engage in shared decision making. Financial incentives, recommendations for SDM from guideline panels, and increased training during medical school and residency are all forces that should increasingly make this kind of care more available.
As patients, you need to get involved in order to advocate for this care. Patients need to stand strong and speak up. When it comes to your physical and/or mental health, you deserve nothing less than a provider who will educate you, listen to you, and offer suggestions responsive to your individual needs. As patients, the more you ask for shared decision making, the faster it will happen.
Editor’s Note: This is the first post in our series about patient-centered treatment outcomes, shared decision making, and other issues that provide patients and families with more power and authority in driving treatment for mood disorders. Care for Your Mind previously ran Dr. Williams’ post in July 2016, but we are using it again for the excellent background and forward-looking information it conveys.
What do you think?
- What has been your experience with shared decision making?
- What would you like your healthcare provider(s) to do differently so that you feel more in charge of your treatment for depression or bipolar disorder?
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John W. Williams Jr., MD, is Professor of Medicine and Psychiatry at Duke University. He received his bachelor and MD degrees from the University of North Carolina-Chapel Hill, and completed residency training in Internal Medicine at the University of Iowa and a research fellowship at Duke University. He is Director of the Durham VA Evidence Synthesis Program; Scientific Editor of the NC Medical Journal; co-Director for Duke’s Clinical Research Training Program; and a faculty member in the Center for Health Services Research in Primary Care at the Durham VAMC. He also co-directed the MacArthur Initiative on Depression and Primary Care. Dr. Williams received a Generalist Physician Faculty Scholar Award from the Robert Wood Johnson Foundation and an Advanced Career Development Award from the VA Health Services Research Program. Dr. Williams is board certified in Internal Medicine and active in resident physician education.
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