Effectively engaging patients in everyday health-care decisions

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Applied Evidence

Effectively engaging patients in everyday health-care decisions

J Fam Pract. 2017 October;66(10):E1-E6

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References

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How do personal and professional recommendations differ?

Personal recommendations arise from clinicians considering what they themselves might decide if they were in the patient’s position. Such recommendations are inappropriate because every person has unique values and priorities.

In contrast, professional recommendations stem from the clinician’s knowledge of the best available evidence, his or her understanding of the patient’s values, and his or her weaving of these pieces together in the context of the patient’s specific clinical presentation. Experienced clinicians bring all 3 elements of SDM to bear in making professional recommendations, even if these recommendations are at odds with what they might choose for themselves.

EBM and SDM: Not so different after all?

Another way to understand the legitimacy of a professional recommendation is to view the parallels between SDM and EBM. From the outset, EBM positioned itself as arising from the best available evidence, the patient’s values, and clinical expertise²⁹—elements that are strikingly similar to the components of SDM.

Although commonly overlooked, the concept of EBM recognizes that established evidence alone is not sufficient for decision-making.³⁰ Additionally, EBM allows for making a recommendation that may not appear to be guideline-based, because guidelines typically do not take into account individual patient preferences.^30-32 What’s more, both EBM and SDM highlight the essential contribution of the clinician’s judgment about his or her patient’s unique presentation.

While personal recommendations have no place in medical decision-making, clinicians should offer a professional recommendation, along with the rationale.

Thus, both EBM and SDM are dependent on the professional communicating a recommendation to the patient. This communication involves not only making clear what one recommends, but also why one recommends it. For example, a clinician might say the following to a patient with worsening asthma symptoms:

“The asthma guidelines give us 2 treatment options. We can either double the dose of your inhaled corticosteroid, or start a 5-day course of corticosteroid pills. Given your concerns about the adverse effects of the pills, and the moderate severity of this exacerbation, I recommend doubling the dose of your inhaled corticosteroid. We can reconsider the pills if your symptoms worsen or if you don’t improve within the next week. How does that sound to you?”

An informed choice. Explaining the evidence, articulating the patient’s values, and summarizing the clinical elements that went into the clinician’s recommendation clarifies and signals to the patient that this is a professional recommendation. Ultimately, the process of SDM concludes with the patient considering the clinician’s recommendation and making an informed choice from the available options.

CORRESPONDENCE
David J. Satin, MD, 2020 E 28th St., Minneapolis, MN 55407; sati0003@umn.edu.