Posts (4)

2 days ago · Technical versus Humanistic Shared Decision Making revisited: Evaluating its occurrence

Submitted by Marleen Kunneman & Victor Montori

In an earlier post, we reflected on technically correct and humanistic shared decision making (SDM). In our view, it is unclear “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 called to look beyond what is technically correct, to uncover humanistic SDM and caring conversations.

We recently published a systematic literature review in which we assessed the extent to which evaluations of SDM assess the extent and quality of humanistic communication, such as respect, compassion, and empathy. We looked for studies evaluating SDM in actual clinical decisions using validated SDM measures. We found 154 studies, of which only 14 (9%) made at least one statement on humanistic communication. This happened in framing the study (N=2), measuring impact (e.g., empathy, respect, interpersonal skills; N=9), as patients’ or clinicians’ accounts of SDM (N=2), in interpreting the study results (N=3), and in discussing implications of the study findings (N=3).

In addition, we looked whether the validated SDM measures used contained items on humanistic communication. The eleven SDM measures used contained a total of 192 items. Of these, only 7 (3.6%) assessed aspects of humanistic communication.

Our review shows that assessments of the quality of SDM focus narrowly on SDM technique and rarely assess humanistic aspects of the patient-clinician conversation. We conclude that considering SDM as merely a technique may reduce SDM’s patient-centeredness and undermine its contribution to patient care.

In evaluating technical SDM, we have measured with our eyes and our ears. Perhaps the fox from “The Little Prince” was on the right track when he noted: “It is only with the heart that one can see rightly; what is essential is invisible to the eye.”

The full paper was published in Patient Education and Counseling and can be found here.

This study was part of the Fostering Fit by Recognizing Opportunity STudy (FROST) program, and has been made possible by a Mapping the Landscape, Journeying Together grant from the Arnold P. Gold Foundation Research Institute.


5 days ago · Trust and shared decision making

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.

Oct 29, 2018 · Technical versus Humanistic Shared Decision Making

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!


  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.

Oct 22, 2018 · Listening

Submitted by Dorothea Lagrange

Throughout Europe there are many beggars from poorer countries. They are seldom welcome. What often gets lost in the rhetoric around these individuals is that these are real people, people who are often vulnerable and in need. In Sweden, where I live, I often encounter these beggars. I wish to tell you the story of one of these individuals and how they affected me.

I live in a small village and one day when leaving the market, I noticed an old man sitting on the ground. I had noticed him before, but today he looked especially haggard and was coughing persistently.

I did not know what to do. My heart ached for this man’s suffering, however, there were many stories about these people, mainly from Romania, that they operated some kind of Mafia where they could not keep any money they collected. This internal conflict made me hesitate, yet, I could not ignore the man in front of me, sitting in the cold, dark, wet, winter night. I thought to myself no one would do this voluntarily; his situation must be truly sad to place him here.

I resolved to go back into the market and buy him some food. After a few times of bringing him food, something amazing happened. He began to give me food! I was embarrassed, here was a man with practically nothing giving me what little he had. With no language in common it was hard for us to communicate, but with pantomime and pictures we began to have our own “conversations” and overtime I learned some Romanian. Sometimes we really had fun and laughed together. The other visitors to the shop stared at us sometimes, probably wondering what we were up to.

I found out that I had done what many of my compatriots had done and this man had more food than he could eat! I learned that while food was helpful, what this man really needed was warm clothes and fuel for his car. The car, it turned out, was not for driving as he did not drive, but for shelter and warmth. Additionally, he confided in me that he longed for a proper haircut; something many of us take for granted. After these conversations I had a realization. When I saw him there on the ground I made assumptions about his situation and jumped to a solution based upon my assumptions. I had solved a problem that he did not really have.

It was a reminder that I need to listen and not create solutions before I have figured out the problem. Sometime later he was admitted to the hospital, his years of smoking and tuberculosis had gotten the better of him. Despite his socioeconomic status, he was well cared for and a translator was brought in to help him communicate with the medical team. Additionally, to help him communicate, the nurses made large cards with the Swedish word on one side and Romanian word on the other. One that I was especially fond of, was one that said “coffee”. Someone added on the Swedish side in small letters “with milk and sugar”. The nurses saw him as the individual he was and restored his dignity.

Costel was a man who loved Baroque music and had previously worked in construction. Costel has since passed away, and the last word in Romanian I learned from him was macara, a crane. That however, was not that last thing Costel would teach me. In reflecting on and sharing my experience it is a reminder to always listen. Even if we think it is obvious what someone needs we cannot be sure unless we listen. Also, he taught me that even the poorest of our fellow humans are individuals and stereotypes may often mislead us. Stereotypes may have some grain of truth in them, but they are only part of the picture. It is easy to miss the rest if you don’t open up and allow for listening first.

This insight is very valuable in my daily life as a family doctor. Here, too, listening must come first. This is easily said, but so often in the rush of the day overlooked. Far too often we think we know what the patient wants or needs – and it turns out it is something completely different the patient is looking for. Without knowing what the patient wants, any suggestions about investigations or treatments are not meaningful and patriarchal.

Listening also helps to put stereotypes aside and to see the individual in the encounter. We do have to learn and understand medicine on a solid scientific ground and I am very fond of evidence. We do have to understand the world with data. But we must then go one step further and treat our patients with these data in mind not as a patient like this, but this patient. Who, in this case, loves his coffee with milk and sugar.



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