This site is all about living a longer, healthier life and shared decision-making can help you achieve that important goal. The biggest barrier to a longer, healthier life is chronic disease that develops prematurely. These conditions usually occur early for a definite reason—excess abdominal fat, inactivity, poor diet, smoking and so forth. Preventing chronic disease and slowing the progression of conditions like diabetes involves changes in lifestyle and taking medication regularly. Shared decision making is a fancy term for a discussion that engages the individual to help make the decisions that are important to living a longer, healthier life. Simple, easy changes can make a huge difference.
One source describes shared decision-making like this: “Shared decision-making in medicine (SDM) is a process in which both the patient and physician contribute to the medical decision-making process and agree on treatment decisions. Health care providers explain treatments and alternatives to patients and help them choose the treatment option that best aligns with their preferences as well as their unique cultural and personal beliefs.
In contrast to SDM, the traditional biomedical care system placed physicians in a position of authority with patients playing a passive role in care. Physicians instructed patients about what to do, and patients rarely took part in the treatment decision.” Of course, shared decision-making makes all the sense in the world today. Most death, disability, and cost come from chronic diseases. Actually, shared decision-making is only the beginning. It sets up patient self-management. Patients are only with clinicians for a few minutes every three to six months, so in reality doctors don’t manage chronic disease. Their patients manage it, and that requires a certain knowledge base.
There are three major things patients need to know.
1. They need to understand the nature of their chronic illness. Type 2 diabetes is a great example. In order to succeed with self management, patients must understand that diabetes is a food disease that is related to too much abdominal fat. The excess abdominal fat comes from eating too much sugar, carbs, processed food, and fast food. They must understand that effectively managing diabetes is not just about sugar. Treating the blood pressure, cholesterol, not smoking, and taking an aspirin are just as important.
2. They need to understand why it is worth their time to do something about it. They are building on understanding the nature of their illness. Now they have to know that type 2 diabetes makes us age faster, die sooner, and suffer catastrophes like heart attack, stroke, heart failure, kidney failure, sudden death, blindness and amputation. Using best practices for diabetes can keep them healthy and save them a lot of money.
3. They must understand what they can do about it. By putting a little effort into changing the food they eat, getting some exercise, and taking very specific medications, they can live eight years longer on average free of heart attacks and strokes. They can dramatically reduce their risk of diabetic complications.
When they have learned all that, they are ready for shared decision making. If they have not learned all that, then having them make a decision not based in the best information can be a catastrophe. I have a perfect example. My wife has horrible back pain. Horrible! We wanted to see a physiatrist who specializes in pain relief. We called a spine practice with a physiatrist and they refused to make one for us. They said “You must see a spine surgeon first so that we don’t miss something dangerous. We has already been seen by an orthopedist, two rheumatologists, and a pain clinic. The all agreed the very small disc bulge on MRI was not causing her pain. We spent about 45 minutes with the spine surgeon giving him the history, undergoing a physical exam, and looking at imaging studies. When he was done, he said, “I can give you an injection of steroids into a facet joint or I can do a laminectomy in the back, flip you over during surgery, and open your abdomen. Then I will put hardware on the front of your spine to stabilize it.”
I guess he thought that he was practicing shared decision making, but the entire encounter scared the hell out of both of us. Had we not been medical people, we would have probably followed his recommendation. I knew right away his advice was a problem. The most rational way to proceed would have been to recommend the minimally invasive facet injection first to see if it worked. If not, then we could discuss the massively invasive surgery. As it turned out, my wife needed neither of his suggestions. She has a terrible and rare autoimmune disease, relapsing polychondritis. She still doesn’t need spine surgery.
Shared decision making is a great idea but best medical practice depends on fundamentals just like blocking and tackling in football. Mastering the fundamentals is essential to success. Patients must know what their disease is about, why your suggestions are worth their time, and what they can do about it. Only then can they participate in shared decision making that matters. When I helped them with that information, they would usually decide to do what they needed to do to protect themselves. There are no easy formulas for success. We have nurses coaches trained in optimal medical therapy who help patients understand these issues.
Such wise words. I'm sorry your wife has to live with such pain - but so glad you were wise enough to ignore the spinal doctor's plan. I hope everyone reads and takes head of this post.
Hey Bill. I've been a devoted fan of SDM for years. Used it in my arthroplasty practice. Data is clear that when patients actively participate (better yet are engaged) in their own decision-making, their outcomes are better, and guess what - the risk of medmal claims are reduced. My value based healthcare mentor, Dr Kevin Bozic's seminal research on this subject nailed it for me. Sure, it takes time and I believe GenAI will be a godsend for this process.
Patients have NO clue what they are getting in to, what the options are and what the extected outcomes would be for each intervention.
BTW, has your wife tried the McKenzie method for spine care?
If not give it a try before surgery. https://pubmed.ncbi.nlm.nih.gov/32925380