March 19, 2019

Trust and shared decision making

By Kirsten Fleming

By Victor Montori

At the beginning of our research journey into shared decision making (SDM), we thought that fostering collaboration between patients and clinicians would promote their partnership and advance mutual trust. Yet, in this trial reported in 2008, we only measured patient trust in the clinician, and we found that disclosing uncertainty (as the intervention required) did not reduce trust in the clinician and may have even improved it despite the measure’s ceiling effect. To my knowledge, we have not measured this outcome in our trials of SDM intervention since then.

Four years earlier, when that trial was being planned, Entwistle reflected on studies that strongly suggested that trust, as a bridge between protective barriers, could favor shared decision making, and shared decision making could result in greater trust in treatment plans. This view was supported by clinicians interviewed by Charles and colleagues. That patients who trust their clinician may be comfortable taking a passive role in following treatment plans their clinician recommends, was substantiated in a report of a survey of Canadian patients that year.

Four years after our publications, in 2012, Peak and colleagues noted a bidirectional relationship between trust and SDM. In focus groups comprised of African American persons living with diabetes, participants reported how clinician efforts to engage them in shared decision making may promote trust, how their own trust in the physician may facilitate their participation in SDM, and how race (including aspects of implicit bias and cultural discordance) can affect both.

And this month, Academic Medicine publishes an important essay by Wheelock, a second year internal medicine resident in Boston, in which she poignantly asks how might we develop relationships of trust needed for shared decision making as industrial healthcare destroys any vestige of continuity of care.

As we review the videos that are produced in the course of the conduct of our clinical trials of SDM interventions, I have noticed another angle in the relationship between trust and SDM, which, as far as I know, remains largely unexplored. We have caught clinicians, using SDM tools in a manner that reveals they simply do not trust their patients to wisely consider the issues and contribute to form care that fits their life situation. Instead, they seem to use the tools as a speaker would use PowerPoint, to build the case for a particular action, to argue in an uninterrupted monologue that concludes in a strong recommendation. It is clear that these clinicians have met these diseases before, but not the people who have them. Nonetheless, the encounter will finish, and the clinicians will know little about these people or their situation, satisfied that they got consent to proceed as they thought would be appropriate, perhaps even before entering the consultation.  It is as if their professional commitment to the welfare of their patients prevents them from running the risk of trusting the patient into the decision making process. They appear afraid that these patients may enter a conversation that may finish at an impasse, at a disagreement, or at a substandard plan. The issues discussed in the last two decades that applied mostly to patient trust in the clinician, may need to be explored in the opposite direction, with an eye on the harmful effect of industrial healthcare.

SDM researchers may therefore do well in considering clinician trust in the patient as a potential modifier – barrier or facilitator – of the collaborative work necessary to form programs of care that make sense and advance the situation of patients.

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