It is more than 30 years since I first heard the expression ‘patient empowerment’, 25 years since I heard ‘shared decision making’, and 12 years since Edwards and Elwyn first published their multi-author edited volume Evidence-Based Patient Choice.1 Even the stirring maxim ‘No decision about me without me’ is beginning to sound old hat.
Few of us are opposed to patient autonomy or shared decision-making. But there is a substantial gap between what we support in principle and what we can or do deliver within the confines of a 10-minute consultation.
Be honest. What happens when a patient attends your surgery with symptoms suggestive of sciatica? Let me guess. You examine them, order some tests, and then have a rather blurry conversation about how (on the one hand) their symptoms may resolve with physiotherapy but, (on the other hand) they may like to see a specialist because some cases will need an operation. The patient expresses a vague preference for either conservative or interventionist management, and you, (respecting their ‘empowered’ views) go along with their preference.
You may have tried using a more structured approach to shared decision-making, for example, by logging on to an online algorithm or by using pie charts or pre-programmed spreadsheets to elicit numerical scores of how much your patient values particular procedures and outcomes vis a vis one another. You or your patient may have abandoned such tools as technocratic, time-consuming, overly quantitative, and oddly disengaged from the unique personal illness narrative whose restitution you both seek.
The good news is that our friends working in the field of shared decision-making have recently acknowledged that the perfect may be the enemy of the good. Most discussions about management options in general practice do not require, and may even be thrown off kilter by, an exhaustive analysis of probabilities, risks, and preference scores. What most people want is a brief but balanced list of the options, setting out the costs and benefits of each, and including an answer to the question ‘what would happen if I went down this route?’.
Enter the option grid2 (http://www.optiongrid.org): the product of a collaborative initiative between patients, doctors, and academics. An option grid is a one-page table covering a single topic (so far complete are sciatica, chronic kidney disease, breast cancer, tonsillitis, and a dozen more). The grid lists the different options as columns, with each row answering a different question (such as, ‘what does the treatment involve?’, ‘how soon would I feel better?’, and ‘how would this treatment affect my ability to work?’).
The reason I see this approach as a progression from more algorithmic approaches to shared decision-making is that the information is presented in a format that allows both reflection and dialogue. The grid can be printed off (or indeed, the patient can be given the URL) and invited to go away and consider the options before returning for a further consultation. And, unlike the previous generation of shared decision-making tools, neither the patient nor the clinician needs to be a geek to use them.
Why not give them a go?
- © British Journal of General Practice 2013
