Bad SDM? Is there any other?

I don’t like shared decision making (SDM) in medicine. In my experience, the word ‘shared’ is still an aspiration and even that might be too optimistic. In this post, I want to respond to an article which aims to bust 12 myths about it. I would like to suggest that it goes the wrong way about it.

Let me just start by saying that it is a good article. It’s well argued, the evidence is well-presented, within the frame it operates, it’s excellent, in fact. The only problem with it is that I am as sceptical about SDM, as I have been. Perhaps even more, to be honest. Why? Because it doesn’t address at all my concerns about SDM. Those concerns don’t even register for the author. The article looks at the SDM from a god-like position of reviews and standard deviations and my interaction with my doctor is just somewhere deep under the radar. And what I would like to do in this post is to (attempt to) challenge the comfortable thinking behind SDM research. So, below I am dealing with some of the myth-busting arguments in the article. For space (and laziness), I’m not dealing with all of them.

Myth #2: In shared decision making, patients are left to make decisions alone.

The author writes:

The idea of balance and respect between the two partners is fundamental to shared decision making and one of its main purposes is to take advantage of both parties’ expertise

What exactly is this balance? What if the doctor doesn’t respect me? Even better – what if I don’t respect the doctor? Believe me, it does happen! But let me up the ante, the idea of a partnership between the doctor and myself is just, do forgive me, laughable. In order to even start thinking about it, you would need to stop taking liberties calling me by my first name; I would need to have a better chair, one which doesn’t require me to do acrobatics allowing me to face you; you would need to stop telling me that I can only mention one problem, as if how I feel can be compartmentalised.

There is the Polish word petent. It is translated into English as ‘applicant’, but this translation doesn’t render the connotations of the word. Petent positons me as an inferior ever-begging applicant entirely at your mercy. And I often feel exactly like that. Not always, but often enough not to want to entertain the idea of a partnership. “Your life in my hands” has an interesting counter-interpretation, doesn’t it? So, please, stop this partnership nonsense. Give me a break.

Myth #3: Not everyone wants shared decision making

Why is it a myth? I don’t want shared decision making and I wish you would respect it and not seek ways to undermine it. I don’t want it because I don’t think it’s possible, or, if you wish, what you call shared decision making is just a label for a variety of communicative activities which are far from homogenous. The author writes:

This argument may stem from the fact that assuming an active role in the decision-making process remains particularly difficult for vulnerable patient populations

Why?! I probably don’t count as vulnerable, moreover, I am probably quite well-informed and this is precisely why I reject it. I simply understand the parameters of SDM. You choose when to engage in SDM, the final decision is always yours. What’s ‘shared’ about it?  I also wonder why the ‘myth’ that not everyone wants SDM is refuted by benefits from SDM. It’s a bit disingenuous, isn’t it?

In a nutshell, you see, I don’t want to engage in SDM, because for me it’s founded on a sleight of hand. You allow me to speak to you and I don’t want to enable you. No? Well, have a look at a title of one of the articles quoted by the authors:

Paternalism or partnership? Patients have grown up-and there’s no going back

I mean, can it get more patronising? But, I guess, I am required to say, oh thank you, the wise one, for noticing that I’m not a nitwit I have been and I can be entrusted with decisions you will let me take. Before, obviously, I couldn’t take them, because, even though I am a middle-aged professor with 5 academic degrees, I was not a grown-up. A child in the mist. That’s just me. Thank you again for empowering me…You do see that all this empowering it like an emetic….

Myth #4: Not everyone is good at shared decision making

It really beats me why call it a myth. If the author writes:

Shared decision making is not an inborn talent but consists of specific behaviours that can be taught.

then surely, not everybody can be equally brilliant, no? I also wish medics understood that communication is not behaviour. It’s action, it’s practice, but not behaviour! But what irritates me here is that this ‘myth’ makes precisely the assumption that all medics are just brilliant. I’d better offer no more comment, as my lack constructive criticism might go too far.

Myth #5: Shared decision making is not possible because patients are always asking me what I would do

I really don’t understand why this is a myth again. And if you read what the author says, it actually is not. I keep saying that I hardly ever have knowledge to fall back on. What I have is, hopefully, the good sense and education of a medic. Yes, I do say it with some trepidation.

 

The same critiques can be made of other ‘myths’. The authors take the available evidence and run away with it, while  I wish they started to think about this evidence from my point of view, the patient’s. For, you see, I really don’t care that studies suggest this, other studies confirm that. I care much more about Dr X sitting in front of me and asking me:

Which medication would you like me to prescribe for you?

which is a question I had actually been asked. I’m fairly certain the medic was ‘doing SDM’ and I really don’t care for arguments that this is SDM done badly. I really don’t. This is SDM I am faced with and that’s SDM I know. So, please don’t tell me that studies suggest that SDM is something different. I haven’t seen any other. It’s always a clumsy attempt to ask me the idiotic ‘empowering question’ which only baffles me as I try to remain polite.

Now, I don’t really know the literature on SDM, which is by now vast. Yet, instead of reading an article on myths about SDM, I would like an article asking the following questions. They are just off the top of my head:

  1. When do doctors do SDM, both globally (what kind of decisions) and locally (when in interaction)?
  2. Who opens SDM and who closes? How is it done?
  3. What’s the process like? Show me transcripts! In particular
  • a. how is it taken up by patients?
  • b. how is it opted out of?
  • c. what kind of questions are asked?
  • d. what kind responses are given?

4. What’s the role of decision aids, how are they constructed and engaged with? In particular:

  • what kind of evidence is discussed?
  • who relies accesses decision aids?

Yes, I think shared decision making should be studied qualitatively (I know that there are some qualitative studies, I think there should be much more). Only then do you actually explore its processes and practices, and you study them in context. And by studying SDM in context I mean both the global context of an asymmetrical relationship, laced with power in its every aspect, and in the context of an interaction here and now. When you have, I might change my mind about it. But before you do, please, stop wasting my time.

 

4 Comments
  1. “the idea of a partnership between the doctor and myself is just, do forgive me, laughable”

    I agree with a lot of things you wrote here – as usual, dear Dariusz. But I disagree that the “idea of a partnership” is laughable. I think, the idea of a partnership is great and important – whether we will ever get there is, however, questionable. And yes, reading accounts of patients’ experiences with doctors (yours and others) make me also doubt that this is going to happen any time soon.

    1. Dariusz Galasinski

      Christiane, thank you for commenting. I guess what I wrote is ambivalent. No, the idea is not laughable in principle. It’s a great idea, but I don’t think anyone as any ideas how to make it happen. Neither do I, incidentally. What’s laughable is that today we can speak of partnership. And to be honest, for me it’s just irritating.

      But I want to be very clear. I think that pronouncements of partnership often come from genuine concern about how healthcare is provided. Many medics genuinely want to care for me, their patient in the best possible way. And they work hard to make it happen. But I also think that many of them need a reality check. Come and sit on a conversation your average provincial doctor has with their average patient and see what SDM is like. And you will be in for a shock!

      A couple of days ago, I was speaking to an academic psychiatrist. I agreed with everything she said. In fact, I was quite taken aback by the depth of reflection and understanding about communication. The chasm between the, shall I say, reflective elite of the profession and the provincial shopfloor is much larger than the ‘elite’ understands and wishes to admit. Bascially, there are doctors and doctors. And your average patient has never seen the first group and has no idea what healthcare could actually be like.

  2. I went to a talk at Oxford about 3 or 4 years ago The audience mostly academics or medical professionals, The speakers were eminent professors from the US etc. As a lay person and a patient I was perplexed to hear that this shared decision making was still a theory and not a practice in medicine. But as you point out ultimately it is the Dr who holds all the power. We can talk all we like about options but the only decision I can make I guess as a patient is to not take up the option. Probably I can’t choose what options I’m given. It is and always will be an unequal partnership.

    1. Dariusz Galasinski

      At least they were fairly realistic about what happens.

      As for options I tend to agree with you. It’s also worth remembering, however, that not taking an option can have consequences. And, especially in psychiatry, such refusal might end up with you being declared as not having insight.

Leave a Reply

Your email address will not be published.

Loading ...