Shared decision making in realistic medicine: what works
Synthesis of recent evidence on the current use of shared decision-making in Scotland, and international evidence of what works in encouraging greater use of shared decision-making in clinical consultations.
5. Conclusions and next steps
In conclusion, this report aimed to identify the existing barriers to further uptake of SDM, along with what can be done to encourage greater engagement of SDM, in clinical consultations in Scotland by way of a synthesis of the recent academic and policy literature.
The report highlights that there is an increasing drive in Scotland towards Realistic Medicine and SDM. In terms of the barriers to greater engagement, the existing evidence highlighted a multitude of perceived and actual barriers, within the areas of knowledge, expectations and around 'the meaningful conversation'. Many of these barriers mapped onto the key conditions that were identified as necessary for an SDM process to be enacted. These key conditions were discussed at length in Section 4 and may be the most important finding of this report.
Further studies into these key conditions could be conducted to further emphasise their importance and impact. Additionally, this report has highlighted a range of tools, skills and attitudes that can, and in some cases have been implemented to, encourage greater SDM engagement in Scotland.
Overall, changes in attitudes at each level, and ensuring existence of the key conditions provide the best examples for encouraging greater SDM. However, there also needs to be greater recognition that involvement in an SDM process is not necessarily merely accepted or not. It can be 'a state and not a trait' (Fisher, et al., 2018, p. 6) and level of involvement may depend on the seriousness of the decision, or who the encounter is with.
Finally, the table below summarises the main issues and solutions suggested in this report.
Table 4: Summary of main issues and suggestions solutions identified in this report
| Issue |
Suggested solutions |
|---|---|
| SDM creates new patient-clinician power dynamics |
Raise clinician awareness 'SDM in practice'; training on communication skills e.g. role-plays; raising public awareness of the new power dynamics; Raise awareness that some patients (e.g. older people) may not welcome SDM |
| Lack of trust/ familiarity between patient/ clinician |
Ensure continuity of care where possible; Highlight statistics on consultation time use to encourage clinicians to give patients more time to talk; Implement evaluation tools to measure SDM impact and increase the evidence base |
| Clinicians feel they are 'already doing SDM' |
Raise clinician awareness of 'SDM in practice'; Communication skills training e.g. role-plays; Contact with SDM champions |
| Low knowledge of 'SDM in practice' |
Raise clinician awareness of 'SDM in practice'; Communication skills training e.g. role-plays; Contact with SDM champions |
| Lack of time to undertake SDM |
Raise awareness of evidence highlighting that SDM (and use of decision aids) does not have to make consultations longer; Highlight statistics on consultation time use to encourage clinicians to give patients more time to talk |
| Misaligned views of patient preferences |
More public training/ education campaigns on how best to discuss 'what matters to you', patient preferences; Clinician database with up-to-date benefits/risks for treatments |
| Fear that undertaking SDM could lead to no/bad treatment from clinician |
Raise public awareness of SDM to increase confidence of public in the process; Implement evaluation tools to measure SDM impact and increase the evidence base |
| Poor environment/ surroundings for SDM |
Conduct further research on impact of surroundings on SDM through patient surveys/ piloting different 'SDM environments' (e.g. removing barriers such as desks and computers) |
| Issues around low patient health literacy |
More public training/ education campaigns on how best to discuss 'what matters to you', patient preferences; Clinician training (role-plays) on how to conduct SDM with people with lower health literacy (e.g. use of clear/ simple language) |
| Lack of belief that SDM will happen |
Promote SDM at national level e.g. promotion by CMO and Board level stakeholders; Implement evaluation tools to measure SDM impact and increase the evidence base |
5.1 Recommendations
The following recommendations require consideration from policymakers, as well as relevant stakeholders at a local and national level:
- Implementation of tools to measure and evaluate the impact of SDM (e.g. patient and clinician satisfaction, and statistics on waste and variation);
- Creation of a training programme to improve communication skills of clinicians on how to conduct meaningful conversations;
- More training and education (for patients, clinicians and boards) to raise awareness of how SDM can be practised (and to highlight the evidence that SDM does not have to add more time to consultations);
- More public training and education campaigns on how best to discuss: 'what matters to you'; patient preferences; and promote better 'continuity of care';
- Easy access up-to-date information on benefits/ risks of various treatments, and improved access to information on patient preferences.
- Identify what information would best help patients make healthcare decisions;
- Promotion of clinical, and system level (e.g. national-level stakeholders and CMO) SDM champions to promote and foster attitudes that are receptive of SDM;
- Creation, and maintenance, of a culture that appreciates the importance of SDM. e.g. suite of complementary policies related to SDM and person-centred care.
In terms of future and further research, this report provides four suggestions:
1. There are still gaps over how best to measure to impact of SDM, an issue that is frequently mentioned in the literature (Legare & Thompson-Leduc, 2014),. Additional research could subsequently give it more weight in policy contexts (and provide a framework for the first Policy Recommendation) and raise the public awareness further, especially if a common set of validated measures were identified.
2. The role of the key conditions (Gulbrandsen, et al., 2016) and surrounding environment (Joseph-Williams, et al., 2014) to help or hinder an SDM process.
3. Obtaining a better understanding of what makes a patient and clinician label a decision as 'shared', as research has highlighted some inconsistencies between the views of the two groups (Leppin, et al., 2014; Shay & Lafata, 2015).
4. Research on why certain treatments become less popular after an SDM process, to gain a better understandings of patient preferences and outcomes, as patients tend to choose less treatments as they become more informed (Mulley, et al., 2012).
Contact
Email: RealisticMedicine@gov.scot
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