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October 29, 2018

Technical versus Humanistic Shared Decision Making

By Kirsten Fleming

Submitted by  Marleen Kunneman, Fania R Gärtner, Ian G Hargraves, Victor M Montori

 

In a recent commentary published in the Journal of Argumentation in Context, we aimed to draw a contrast between technically correct shared decision making (SDM), and a humanistic approach to SDM.1 We stated:

“To address a patient’s problematic situation, patients and clinicians must work together to figure out a way forward that maximally supports meeting the patient’s goals, such as cure or better quality of life, while minimally disrupting their lives and loves, such as family life, work, or leisure. This work takes place in a conversation in which patients and clinicians test, or ‘try on’, the available options as ‘hypotheses’ until they identify one that fits best. The option that ‘fits best’ is the one that makes the most intellectual, emotional, and practical sense. This means that not only do patients and clinicians know and understand that it is the best option at hand, it also feels right and can be implemented in the life of the patient. The conversational dance between the patient and clinician2 and the trying out of different options and making sense of these options is sometimes called shared decision making or SDM.2,3 SDM shifts the focus of healthcare from care for ‘patients like this’ to care for ‘this patient’.”

We commented on a study by Akkermans et al, who studied the stereotypicality of argumentation in SDM encounters.4 We highlighted that “focusing on learning and using the correct communication (or techniques or steps of SDM) only makes sense if using these techniques and structures advances the situation of the patient.” We noted that:

“Since the emergence of SDM, research and implementation has primarily focused on getting the structure of SDM right: to take the right steps at the right time. It suggests that there is a technically correct sequence of steps, one that is best able to lead to identifying the best option, the best care for this patient.”

We noted the value of this approach insofar as it has shown that ‘technically correct SDM’ is rare in practice.7,8 Yet, it is unclear to us whether having a technically correct structure of the SDM process improves the likelihood that the care decisions made will contribute to improve the patient situation. We worry that focus on technical steps may encourage clinicians to ‘go through the motions’ or ‘check the boxes’ to achieve efficient productivity. This may indicate that current SDM evaluations “may lack validity, overestimate the occurrence of SDM as a caring process, and, to the extent that the conversation is necessary for SDM to exert its salutary effects, may underestimate the impact SDM could have on patient outcomes when applied in its caring form.” A focus on technically correct SDM, and on policies that promote it, may not improve the patient situation.

We concluded:

“The way forward may need to focus on responding to each patient’s problematic situation, and then explore the structures necessary, of SDM and argumentation, to achieve this response. We believe that in shifting this focus, we will look beyond what is technically correct, to uncover humanistic SDM and caring conversations.”

Recently, our teams (KER Unit and dept Medical Decision Making, LUMC) have been exploring the differences and value of technical versus humanistic SDM and its assessment. Part of this work has been made possible by Mapping the Landscape, Journeying Together grants from the Arnold P. Gold Foundation Research Institute. Stay tuned for the findings of these projects!

References

  1. Kunneman M, Gärtner FR, Hargraves IG, Montori VM. Commentary on "The stereotypicality of symptomatic and pragmatic argumentation in consultations about palliative systemic treatment for advanced cancer". Journal of Argumentation in Context. 2018;7(2):205-209.
  2. Kunneman M, Montori VM, Castaneda-Guarderas A, Hess E. What is shared decision making? (and what it is not). Acad Emerg Med. 2016;23(12):1320-1324.
  3. Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med 1997;44(5):681-692.
  4. Akkermans A, Labrie N, Snoeck Henkemans F, Henselmans I, Van Laarhoven HW. The stereotypicality of symptomatic and pragmatic argumentation in consultations about palliative systemic treatment for advanced cancer. Journal of Argumentation in Context. 2018.
  5. Stiggelbout AM, Pieterse AH, de Haes JCJM. Shared decision making: Concepts, evidence, and practice. Patient Educ Couns. 2015;98(10):1172-1179.
  6. Elwyn G, Durand MA, Song J, et al. A three-talk model for shared decision making: multistage consultation process. BMJ. 2017;359:j4891.
  7. Stacey D, Legare F, Lewis K, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2017;4:CD001431.
  8. Montori VM, Kunneman M, Brito JP. Shared Decision Making and Improving Health Care: The Answer Is Not In. JAMA. 2017;318(7):617-618.

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