Decision-making in the physician–patient encounter: revisiting the shared treatment decision-making model
Introduction
Although shared treatment decision-making is a concept that has gained widespread appeal to both physicians and patients in recent years, there is still confusion about what the concept means. To help clarify this issue, we published a paper which tried to define shared treatment decision-making and its key characteristics and to show how this interactional model differs from other commonly cited approaches to treatment decision-making such as the paternalistic and the informed models1 (Charles et al., 1997a). The paternalistic model is by now well known and articulated (Emanuel and Emanuel, 1992, Levine et al., 1992, Beisecker and Beisecker, 1993, Deber, 1994, Coulter, 1997). Hence, we concentrated on exploring the differences between the informed and the shared models because these two labels have often been used interchangeably to describe quite different types of interaction between physician and patient in treatment decision-making.
The context for our discussion was a life threatening disease where several treatment options were available with different possible outcomes (benefits and risks or side effects), outcomes could vary in their impact on the patient's physical and psychological well-being and outcomes in the individual case were uncertain. In this context, we argued that a shared treatment decision-making model could be identified as such by reference to four necessary characteristics (Charles et al., 1997a) as follows:
- 1.
At a minimum, both the physician and patient are involved in the treatment decision-making process.
- 2.
Both the physician and patient share information with each other.
- 3.
Both the physician and the patient take steps to participate in the decision-making process by expressing treatment preferences.
- 4.
A treatment decision is made and both the physician and patient agree on the treatment to implement.
In this paper we revisit and add elements to our conceptual framework based on further analytic thinking and our current research on the meaning of shared decision-making to women with early stage breast cancer and to physicians who specialize in this area (Charles et al., 1998). Our revised framework (1) identifies different analytic stages in the treatment decision-making process; (2) provides a dynamic view of treatment decision-making by recognizing that the approach adopted at the outset of any given physician–patient encounter may change during the course of that encounter; (3) identifies different approaches that lie in between the three predominant treatment decision-making models and (4) has practical applications for clinical practice, research and medical education. Before exploring these issues, we briefly review factors that have led to the development of new treatment decision-making models as alternatives to the traditional paternalistic approach.
Section snippets
The rise and fall of paternalism
Prior to the 1980s, the most prevalent approach to treatment decision-making in North America was paternalistic with physicians assuming the dominant role. Underlying this deference to professional authority were a number of assumptions. First, that for most illnesses, a single best treatment existed and that physicians generally would be well versed in the most current and valid clinical thinking. Second, physicians would not only know the best treatments available, they would consistently
Models of treatment decision-making
Both the informed and the shared models of treatment decision-making were developed largely in reaction to the paternalistic model and to compensate for alleged flaws in the latter approach. These three models are the most prominent and widely discussed in the treatment decision-making literature. Key characteristics of each model and how they differ from one another are summarized in Table 1. In Table 1 treatment decision-making is subdivided into three analytically distinct stages, even
Practical applications of the framework
Our revised and updated framework depicted in Table 1 is more flexible and incorporates a more dynamic perspective on treatment decision-making than our earlier model. We think it is also clearer in terms of practical applications for physicians and others. First, the framework provides a description of the various analytical stages in the decision-making process. The framework can be used to educate physicians about these stages and about the defining characteristics of each model. The
Conclusion
In this paper we have revisited and expanded our earlier conceptual framework of different treatment decision-making models. We think this framework is more flexible than its predecessor and recognizes more clearly the dynamic nature of treatment decision-making. Practical applications of the framework have also been discussed. Over the course of our research we have learned that treatment decision-making is a complex process that takes place over time and can involve many individuals rather
Acknowledgements
This research is supported by a grant from the National Cancer Institute of Canada, Canadian Breast Cancer Research Initiative. We would like to thank two anonymous reviewers for their thoughtful comments on an earlier draft of this paper. We are grateful to Reviewer I, in particular, for pointing out that the analogy we use of ‘taking two to tango’ can be extended to incorporate the notion that the lead partner can change depending on the type of dance being undertaken.
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