Although I am grateful for Prof. Daniel Lichtstein's comments on my article,
1
I can hardly refrain from pointing out the wide gap that often exists between the practice of medicine as reflected by many editorials and writings of educators and ad hoc committees2
and what is going on in the “real world.” Nowhere is this gap more striking than in regard to shared decision-making.Shared decision-making is universally lauded, an integral part of the patient's autonomy, and patient-centered care, which is one of the Institute of Medicine's (currently, The National Academy of Medicine) 6 domains of health care quality. Unfortunately, when we look around us and indeed, at ourselves, we cannot fail to note (although confirmed by only a handful of studies) that patient-centered care and shared decision-making are often neglected.
3
,4
Of the many barriers that have been identified by research, the few minutes allotted to the clinical encounter in most countries and settings is arguably the most pivotal. Studies of encounters in primary care done in the 21st century reveal a median consultation time of 9.22 minutes in the United Kingdom, 17.50 minutes in the United States, and ≤5 minutes in 18 countries representing about half of the world population.
5
Clinicians, who have so many obligatory issues to attend to in the care of patients who are now older, more complex, and more culturally diverse than ever, are likely to skip shared decision-making that involves understanding the patient, weighing together preferences and values, and above all, ensuring the patient health literacy and educating them on the decision at hand and alternatives. In 1 study of 3552 clinical decisions, only 0.5% of complex decisions were completely informed,3
despite the fact that complex decisions are where patient and family involvement are most required.6
The number of decisions is another factor to consider. In 1 study of hospital encounters, a mean of 15.7 decisions per encounter in internal medicine was found.7
Thus, shared decisions are unquestionably important, but physicians must be better educated in their implementation and provided with more quintessential time.
References
- Sense and sensibility.Am J Med. 2021; 134: 1570-1571
- Defining and assessing professional competence.JAMA. 2002; 287: 226-235
- Informed decision making in outpatient practice: time to get back to basics.JAMA. 1999; 282: 2313-2320
- Why the nation needs a policy push on patient-centered health care.Health Affairs. 2010; 29: 1-7
- International variations in primary care physician consultation time: a systematic review of 67 countries.BMJ Open. 2017; 7e017902
- Shared decision making – the pinnacle of patient-centered care.N Engl J Med. 2012; 366: 780-781
- Clinical decisions presented to patients in hospital encounters: a cross-sectional study using novel taxonomy.BMJ Open. 2018; 8e018042
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Conflicts of Interest: None.
Authorship: The author is solely responsible for the content of this manuscript.
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