The three talk model of shared decision making - Part 1
Another highly cited model of shared medical decision making - Shared decision making: a model for clinical practice - was first published in 2012 by Elwyn, Frosch, Thompson and colleagues. 1 In this post, I will review the details of the initially proposed model and in next one about the 2017 update.
The authors defined shared decision making (SDM) as:
“…an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences.”
The aim of the paper was
“… to translate conceptual descriptions into a three-step model that is practical for clinicians. The purpose of this article is to advance a novel, yet pragmatic, proposal about how to do [authors’ emphasis] SDM in routine settings, in short how to integrate good communication skills with the use of patient decision support tools.”
As implied by the definition of SDM used, the proposed model is based on the view that the goal is to promote patient self-determination about decisions regarding their health care choices:
“… achieving SDM depends on tasks that help confer agency [authors’ emphasis] where agency refers to the capacity of individuals to act independently and make their own free choice.”
The model describes a method for providing information and promoting deliberation that will result in a decision based on a patient’s informed preferences. It is presented as a series of three conversations, hence the name “three talk model”. The authors note that this paper presents a simplified version of the proposed model to improve the clarity of the presentation. They caution readers to remember that the actual practice of clinical decision making is dynamic and should not be considered as a simple, purely stepwise process:
“We realize that this model is a simplification of a complex, dynamic process, yet its simplicity may help others accomplish and teach shared decision making. That was our goal.”
The three steps are:
1. Choice talk, where the need to make a decision because more than one reasonable option exists is conveyed to the patient. The model specifically encourages practitioners to encourage patients to participate in a decision making process and not just defer to the practitioner’s recommendation without further consideration.
2. Option talk, where the options are identified and their relative advantages and disadvantages are reviewed preferably with the use of a patient decision support tool that will “…make options visible and may save time”.
3. Decision talk, where patient preferences are elicited and used to select a preferred option or to defer a decision pending further discussion.
The model is described as having two main components: providing information and deliberation.
Providing information involves making sure patients have accurate, high quality information about the decision options. Patient decision aids are noted to be useful for this purpose. It also involves checking to see if patients have misconceptions about the options and, if so, correcting them.
Deliberation is defined as “… a process of considering information about pros and cons of their options, to assess their implications, and to consider a range of possible futures, practical as well as emotional.”
I’ve summarized the model in the figure below, which is adapted from Figure 1 in the original paper. In the original, the three “talk” phases are within the deliberation space. However, my understanding is that the goal of the provider-patient communication components of the model is to support deliberation, so I have separated the two components in this alternative figure.
Musings
On the shared decision making spectrum originally defined by Charles, Gafni, and Whelan, this model appears to envision shared decision making as an informed patient process. 2 (See the July 22 and July 29, 2022 posts for details about this spectrum.) There is a caution in the text about not “abandoning” the patient and a mention of achieving a practitioner-patient “shared mind” but the thrust and intent of the paper is clearly patient choice rather than a shared choice. Of note, there is no mention that the ultimate choice should be acceptable, even if not considered ideal, by both practitioner and patient.
One of the basic reasons for promoting shared decision making is that a patient may have personal concerns and considerations that need to be included in the decision making process. Therefore I was surprised to find that there is no mention of asking the patient what information is needed to adequately compare the advantages and disadvantages of the decision options in any of the talk conversations.
The importance of deliberation in making a decision is suitably emphasized, but never described in any detail. Given the emphasis on a communication-based process, my understanding is that the model assumes that good deliberation can occur naturally, without any support, as long as the communication is conducted in a skillful manner. I think this is a major weakness of the model as originally proposed.
It is well known that decision making, particularly about high stakes decisions involving tradeoffs between the pros and cons of multiple decision options, is a complex process that is subject to a number of cognitive biases that can result in potentially avoidable poor choices. Moreover, although the three talk model recognizes that clinical decisions are made under conditions of uncertainty both in describing the pros and cons of decision options and possible future outcomes, I see no provision in the model for effectively managing these uncertainties.
Like communication, decision making is a skill that can be improved through the use of proper techniques and training. Proven methods for improving the quality of a decision making process that can be readily adapted for clinical use are available. It will be interesting to see if any of the many articles that have cited this paper have addressed and corrected this major deficiency in the three talk model as initially proposed. (If anyone knows if this has been done, please let me know. The prospect of combing through more than 2,000 citations is daunting.)
A final observation - the model seems to assume that practitioners are suitably well informed about the pros and cons of decision options appropriate for individual patient circumstances. Although ideal, I suspect that ten years ago many practitioners lacked ready access to quality information about the advantages and disadvantages of the options for many clinical decisions. (I wonder how many do now.) It would have been nice, therefore, to add that the development of information support systems formatted to directly support high quality decision making is an essential requirement for effectively implementing the three-talk model in clinical practice.
Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared decision making: a model for clinical practice. Journal Of General Internal Medicine. 2012;27(10):1361–7.
Charles, C, A Gafni, and T Whelan. “Shared Decision-Making in the Medical Encounter: What Does It Mean? (Or It Takes at Least Two to Tango).” Social Science & Medicine 44, no. 5 (March 1997): 681–92.