Shifting from Shared to Collaborative Decision Making: A Change in Thinking and Doing

Laura O'Grady, PhD; Alejandro (Alex) Jadad, MD, DPhil FRCPC

Disclosures

J Participat Med. 2010;2:e13 

In This Article

Abstract and Introduction

Abstract

Despite its theoretical appeal, the concept of shared decision making in the clinical encounter has yet to translate into practice. In this article we revisit this approach and suggest an alternative we have labeled "collaborative decision making," which may lead to more equitable and more favorable outcomes. We define collaborative decision making as a process of engagement in which health professionals and patients (and their loved ones) work together, often using information and communication technologies to understand clinical issues and determine the best course of action. Moving beyond the two-way knowledge exchange proposed in the shared decision making model, we outline a scenario in which the exchange of information leads to the development of a stronger partnership between the patients and the health professionals. We suggest that an organization readiness for change framework be used to explore how information and communication technology can facilitate effective patient partnerships as health care becomes increasingly complex and challenging.

Introduction

"Some problems are so complex that you have to be highly intelligent and well-informed just to be undecided about them."
–Laurence J. Peter

In 1980, Dr. F.J. Ingelfinger, a former Editor-in-Chief of the New England Journal of Medicine and renowned gastroenterologist, recounted his experience with decision making as a clinician-turned-patient in an article he entitled "Arrogance".[1] Following a diagnosis of adenocarcinoma at the gastroesophageal junction, he described how he drew on his own expertise and relied on advice from his colleagues regarding treatment options. He experienced great difficulty weighing information from these various sources to make decisions about his care. After much deliberation, Dr. Ingelfinger concluded that another clinician should make decisions about his treatment.

Perhaps it was easier for Ingelfinger to let go of his decision making option–he already had more knowledge in this area than most people. He made an informed decision not to make decisions about his treatment. He felt sufficiently empowered to "disempower" himself, eventually pursuing a mode of decision making that removed the burden from his own shoulders.[1] In addition to this "paternalistic" mode chosen by Dr. Ingelfinger, where the clinician makes the decisions, two alternatives have been proposed. One, known as "autonomous", refers to situations in which the patient makes the decisions, in some cases with clinicians acting as sources of information.[2] In 1980 American actor Steve McQueen reportedly made an "autonomous" decision for his treatment of mesothelioma. When he was given a grim prognosis, he sought alternative care in Mexico.[3] This mode is not commonly used throughout the world, since patients are often limited to the treatment options available to the clinicians at hand.[4] Another model is known as "shared decision making".[2] It describes a process by which clinicians (mostly physicians, but also nurses and other allied health professions) and patients converse about various options and preferences, reaching a decision by consensus. These options all focus on who is making the decision–the patient, the clinician, or both.

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