Dealing with the Lack of Time for Detailed Shared Decision-making in Primary Care: Everyday Shared Decision-making
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and Rodney A. Hayward, MD1,2,3
1
VA Center for Clinical Management Research, Ann Arbor, MI, USA; 2Institute for Health Policy Innovation, University of Michigan, Ann Arbor, MI, USA; University of Michigan Medical School, Ann Arbor, MI, USA.
3
Policymakers and researchers are strongly encouraging clinicians to support patient autonomy through shared decision-making (SDM). In setting policies for clinical care, decision-makers need to understand that current models of SDM have tended to focus on major decisions (e.g., surgeries and chemotherapy) and focused less on everyday primary care decisions. Most decisions in primary care are substantive everyday decisions: intermediate-stakes decisions that occur dozens of times every day, yet are nontrivial for patients, such as whether routine mammography should start at age 40, 45, or 50. Expectations that busy clinicians use current models of SDM (here referred to as “detailed” SDM) for these decisions can feel overwhelming to clinicians. Evidence indicates that detailed SDM is simply not realistic for most of these decisions and without a feasible alternative, clinicians usually default to a decisionmaking approach with little to no personalization. We propose, for discussion and refinement, a compromise approach to personalizing these decisions (everyday SDM). Everyday SDM is based on a feasible process for supporting patient autonomy that also allows clinicians to continue being respectful health advocates for their patients. We propose that alternatives to detailed SDM are needed to make progress toward more patient-centered care. J Gen Intern Med DOI: 10.1007/s11606-020-06043-2 © Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2020
time and so little to do. Wait a minute. Strike “S othat.muchReverse it.” [Willy Wonka]
In recent discussions about the slow uptake of shared decisionmaking (SDM), one controversy has been the extent to which time is a barrier (see Box 1 for key elements that characterize SDM). Clinicians consistently emphasize that time is the most important barrier to implementing SDM.1–3 Many SDM Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11606-020-06043-2) contains supplementary material, which is available to authorized users. Received September 17, 2019 Accepted July 7, 2020
advocates remain skeptical, citing that better SDM does not, in fact, appreciably increase visit length.4, 5 Some even maintain that lack of time for SDM is a myth.5, 6 Although we agree that any change in practice can summon a perceived “lack of time” that has more to do with priorities than insufficient time, we insist that time-constraints are quite real in the primary care context.7, 8 Moreover, even though some desire a low threshold for advocating for detailed SDM, it is undeniable that detailed SDM for all substantive medical decisions in primary care is not realistic.9–12 Box 1 Elements that characterize sha
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