Should shared decision making be re-branded?
Gerwing and Gulbrandsen think the name might be part of the problem and propose that practitioners would be more willing to ‘contextualize decisions’. [1]
Rebrand: to change the way that an organization, company, or product is seen by the public. [2]
In 2019, Gerwing and Gulbrandsen wrote an interesting perspective on the difficulties implementing shared decision making in practice. [3] They succinctly summarize the current situation as one where academics are busy creating conceptual models of shared decision making, policy makers are busy recommending and even mandating shared decision making, but clinicians are not adopting the practice.
Some have proposed that the reason for the poor uptake of shared decision making is that the initial conceptualizations of shared decision making were too complex to be feasible in clinical practice. This idea has led to efforts to simplify the process. A good example of this approach is the 3-talk model which has been recently described as:
“…as a purposefully simplified representation of a complex adaptive iterative way of constructing a supportive climate for working through difficult choices”. [1]
In contrast, Gerwing and Gulbrandsen raise the possibility that we are looking at the situation from the wrong point of view:
"As a field, we must face the possibility that rather than setting the bar too high, we may have set it up in the wrong stadium."
They suggest that the term “shared decision making” conflicts too much with the prevailing culture and ethos of clinical practice. In their view, both clinicians and patients feel that health professionals should responsible for ensuring patients receive high quality care and that the term shared decision making can be understood as being inconsistent with this viewpoint. They propose re-branding shared decision making as “contextualizing decisions”, a process where health care decisions take into account relevant patient-related factors such as life circumstances, behaviors, and preferences. In support of this ideas, they report that, in a series of studies, Winter and Schwartz showed that medical students can learn contextualization, doctors who gather contextual information are more likely to use it in patient management, and that poorly contextualized care plans are expensive and lead to poorer outcomes. [4-7]
They conclude:
Phrasing the ideals espoused by SDM as a process of contextualizing decisions is congruent with the biopsychosocial model; it reminds physicians that the patient they serve is a person with a life, beliefs, thoughts, and preferences they must consider, while not being at odds with the ethos and everyday routines of modern medical practice.
Unfortunately, the original article is still behind the journal paywall and not readily accessible to everyone.
Musings
1. I think the strength of this proposal is the suggestion that we really don’t know why it has been so difficult to implement shared decision making in practice. Until we have an accurate diagnosis, solving the problem will continue to be difficult.
2. I believe that most shared decision making models advocate contextualizing decisions by including patient perspectives, priorities and life circumstances and integrating them into clinical decisions. Perhaps the proposed change in terminology could be helpful in fostering understanding of what shared decision making is meant to mean. However, it would be great if someone could come up with a sexier term than “contextualization”.
3. Unfortunately, this article does not go into the details of how to accomplish the proposed contextualization and rebranding process. Perhaps the authors are working on that now. I hope so.
References
1. Elwyn G. Shared decision making: What is the work? Patient Educ Couns. 2021 Jul;104(7):1591–5.
2. Cambridge Dictionary: https://dictionary.cambridge.org/dictionary/english/rebrand
3. Gerwing J, Gulbrandsen P. Contextualizing decisions: stepping out of the SDM track. Patient education and counseling. 2019 May;102(5):815-6.
4. Weiner SJ, Schwartz A. Contextual errors in medical decision making: overlooked and understudied. Acad. Med. 2016;91:657–62.
5. Schwartz A, Weiner SJ, Harris IB, et al. An educational intervention for contextualizing patient care and medical students’ abilities to probe for contextual issues in simulated patients. JAMA 2010;304:1191–7.
6. Schwartz A, Weiner SJ, Binns-Calvey A, et al. Providers contextualize care more often when they discover patient context by asking: meta-analysis of three primary data sets. BMJ Qual. Saf. 2016;25:159–63.
7. Schwartz A,Weiner SJ, Weaver F, etal. Uncharted territory: measuring costs of diagnostic errors outside the medical record. BMJ Qual. Saf. 2012;21:918–24.