Dear All

I haven't had time to go back to the original papers, but my recollection is that the original framework of shared decision-making did not make the distinction below between formulating the problem and agreeing an intervention.  I agree with Piersante that this distinction is an artificial one, and likely to be unhelpful in most instances.

For those interested, I think that the original formulation of shared decision-making came from Cathy Charles and her colleagues:
C. Charles, A. Gafni, and T. Whelan. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc.Sci.Med. 44 (5):681-692, 1997.
C. Charles, A. Gafni, and T. Whelan. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc.Sci.Med. 49 (5):651-661, 1999.

There is in fact very little good evidence for the benefits of shared decision-making, although this is partly because some studies have attempted to apply the model to situations where a single decision needs to be made, and shared decision-making is probably more useful in situations where the clinician and patient have an ongoing relationship, as in primary care and/or in chronic illness.

The following is a systematic review:
E. A. Joosten, L. Fuentes-Merillas, G. H. de Weert, T. Sensky, C. P. van der Staak, and C. A. de Jong. Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status. Psychother.Psychosom. 77 (4):219-226, 2008.

There is also a useful commentary on the kinds of situations where shared decision-making is likely to be more appropriate:
Simon N. Whitney, Amy L. McGuire, and Laurence B. McCullough. A Typology of Shared Decision Making, Informed Consent, and Simple Consent. Ann.Int.Med. 140 (1):54-59, 2004. 

Kind regards.

Yours

Tom


Tom Sensky BSc PhD MB BS FRCPsych
Emeritus Professor of Psychological Medicine
Imperial College
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Occupational Health Department
West London Mental Health NHS Trust
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-----Original Message-----
From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Piersante Sestini
Sent: 06 January 2010 00:35
To: [log in to unmask]
Subject: Re: EVIDENCE-BASED-HEALTH Digest - 9 Dec 2009 to 10 Dec 2009 (#2009-272)

my understanding is that the words "decision making" are used with a 
different meaning in clinical and shared decision making.

In the latter the refer to the way information are processed, while in 
the former to the agents involved in the process (maybe  "decision 
taking"), so they don't seem neither conflicting nor overlapping 
(although, of course, they are concurrent)

According to its advocates, the place of shared DM is after the problem 
has been defined and before the management plas has been decided upon 
(Elwin, Brit J Gen Pract, 1999). I don't agree completely (I think that 
sharing should also be part of the definition of the problem), but it 
seems clear that the process that we call "clinical decision making" has 
already started at that point, and although some form of shared process 
can be acting in the interaction, it mostly happen independently in the 
different actors (i.e. the patient and the health professional)


Where shared decision making seems to clash more with the current EBM 
paradigm, is on its requirement for providing choices rather than 
focusing on the "best" one.

I think that the clash is only apparent, because eventually a "best 
choice" should be selected anyway: the difference being that the choice 
should the result of a shared judgment rather of the judgment of the 
professional alone. Still, integrating it in the current practice of EBM 
   requires some changes in the way most of us see its duties, and on 
the way many EB-guidelines are written.

piersante sestini











Maskrey Neal wrote:
> 
> I'm finding it best to draw a distinction between clinical (or 
> clinician) decision making and shared decision making. Whilst the 
> cognitive approach is common and biases affect both, the power of 
> clinical training in the former and the importance of consultation 
> skills in the latter mean a somewhat artificial distinction helps loads 
> with constructing the data into something meaningful, and making the 
> whole understandable by others. For me the third domain is information, 
> where we in EBM have so far spent most time and effort. Quite right too, 
> but if we want to increase utility we need to some work at the problems 
> of clinical decision making and shared decision making might help.
> 
>  
> 
> Bw
> 
>  
> 
> /Neal/
> 
>  
> 
> Neal Maskrey
> 
> NPC
> 
> Liverpool UK
> 
>  
>