Shared Decision Making (SDM) supports people to understand their options and gives them the opportunity to consider relevant information that might influence their choice1.
We hope that the information on this website will support that process, and be used flexibly by clinicians with their patients.
Before talking more about Shared Decision Making, we would like to highlight two important points about this website:
- It is not the intention that every treatment decision needs to involve a conversation about evidence, numbers or risk. Many (perhaps a majority of) patients would prefer their clinician to make treatment recommendations after their preferences have been taken into account, rather than being told some numbers and asked to make their own decision!
The information in this website may be best used as an additional component integrated into the clinician’s thought process to help shape conversations and decisions.
- This website was designed for GPs, not patients. The language and presentation of information is aimed at (and has been tested with) practising GPs. In our user testing, many GPs said they would share the computer screen (particularly graphics) with patients to explain help explain information. This may be a great idea, but remember to do this sensitively, thinking about how the information may be received and understood, especially if showing information about mortality in clinical trials for example.
Basic principles of shared decision making
Listed below are some excellent learning tools which we’d highly recommend exploring – there is much to learn and reflect upon. These notes are intended as a brief introduction.
Good shared decision making consultations share a number of components, many of which you may be using already:
- “Preference diagnosis” Ensuring a person’s preferences and priorities are expressed and understood. People with differing preferences will make different decisions faced with identical clinical situations and presented with the same evidence. These decisions are “right” for them.
- “Choice talk” Making someone aware that there actually is a treatment choice (rather than one right course of action) with pros and cons.
- “Option talk” Presentation and discussion of the pros and cons of treatment options available at whatever level is appropriate/preferred for an individual. One useful framing of this is the BRAN model:
- what are the benefits?
- what are the risks?
- what are the alternatives?
- what if I do nothing new or different?
- “Discussion talk” Where the clinician and patient “come together” to reach a decision.
- You can’t always assume information given has been understood and will be remembered. The simple “Teach-back” technique can be valuable for checking this.
These elements of a consultation may happen in any order, may take place over a number of different consultations and importantly, decisions can – and often should – be revisited over time.
When it is appropriate to share numerical information with patients, it is important to remember that most humans (doctors included) find statistical ways of thinking about risk difficult. Research on risk communication suggests that:
- Plain language (“natural frequencies”) is a good way to present information: ‘If a hundred people like you … ‘ (like the statements below the infographics on this website). An alternative could be, ‘Out of a hundred possible futures…’.
- Graphical presentations of data can be helpful, but are not preferred or understood by all. Remember we as clinicians are already used to the smiley face charts!
- Absolute Risk Reduction (ARR) is preferable to Relative Risk Reduction (RRR). RRR leads to substantial overestimation of treatment benefits.
- Numbers Needed to Treat (NNTs) often confuse patients (even though doctors quite like them). Maybe best avoided.
- Positive and negative framing is important: ‘Five people out of a hundred will have a heart attack, but ninety-five will not’. Presenting just one of these figures can create large shifts in perspective and affect decision making.
- Communicating strength of evidence can affect people’s choices, i.e., if told something is LOW quality evidence, they are less likely to take up a treatment. In the context of this website, it is worth emphasising that LOW quality evidence does NOT mean totally unreliable (see “Understanding Evidence Quality” section of this website).
References and resources
1)Personalised Care Institute: Shared Decision Making e-learning module 2022
- 30-minute introductory module including the concepts listed above. Free to access.
2)NICE Shared Decision Making Guideline 2021
3)NICE Shared Decision Making learning package 2021
- 4-hour, in-depth six-module e-learning course covering psychology, evidence-based practice, probability and uncertainty, and communication skills. Free to access.
4)University of Cambridge. Communicating harms and benefits in primary care 2018
- 2-hour e-learning package developed by experts in risk communication and tailored for GPs. Free to access.
5)How to communicate evidence to patients 2019
- Excellent open-access paper.
Freeman, A. How to communicate evidence to patients. Drug and Therapeutics Bulletin. 2019. Vol 57:8;119