A Simple Approach to Shared Decision Making in Cancer Screening
When screening decisions aren't clear, this process can help you help your patients.
Fam Pract Manag. 2017 May-June;24(3):5-10.
Author disclosures: no relevant financial affiliations disclosed.
Consider the following patient scenarios:
1. Nancy, a longtime patient of yours, comes to your clinic for a physical. While you are catching up with her, she tells you that the mom of one of her son's classmates was just diagnosed with breast cancer at the age of 41. Nancy is 45 years old and is now concerned that she has never had a mammogram.
2. Shari is a 65-year-old Caucasian woman with no chronic medical problems. You don't see her very often because she doesn't like to visit the doctor, but she's here for a physical. She is a current smoker with a 50 pack-year history of smoking. You see a note from your nurse saying that Shari would qualify for lung cancer screening.
3. Bob is a 58-year-old African American man who presents for a physical with no complaints. He has well-controlled hypertension and hyperlipidemia. He had a prostate-specific antigen (PSA) test in the past that was in the normal range, and his family history is negative for prostate cancer. His wife suggested he should get screened again based on an article she read.
In cancer screening discussions such as these, where patients may have more than one medically reasonable option, shared decision making can be a useful tool for helping patients decide what to do. This article presents “Three models of shared decision-making” and “Three case studies” showing how to use the models in a busy primary care practice.
What is shared decision making, and why do it?
Shared decision making is simply a process that aids a physician and patient in selecting the optimal test or treatment for the patient. It involves a bidirectional flow of information. (See “Shared decision making vs. usual care.”) The physician provides information about the disease, the screening service, and risks and benefits; the patient provides his or her thoughts and values; and together they make a decision. Shared decision making is distinct from informed decision making, where the physician provides information to the patient and then the patient makes the decision.
Although shared decision making is not appropriate in clinical scenarios where the medical treatment is clear, such as antibiotics for meningitis or anticoagulation for a pulmonary embolus, it proves beneficial in situations where more than one treatment or screening decision is valid. With cancer screening, there are many options for primary care patients and good evidence that early detection can lead to decreased mortality and morbidity. But most of the screening methods also have possible harmful effects including over-diagnosis or
Referencesshow all references
1. National Research Council. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001....
2. Barry MJ, Edgman-Levitan S. Shared decision making: the pinnacle of patient-centered care. N Engl J Med. 2012;366(9):780–781.
3. Keevil J, Leaf M, Zelenski A. Patient survey results after use of integrated EHR decision tool. Paper presented at 37th Annual Meeting of the Society for Medical Decision Making. October 18–21, 2015. https://smdm.confex.com/smdm/2015mo/webprogram/Paper8973.html.
4. The SHARE approach. Agency for Healthcare Research and Quality website. http://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/index.html. Updated February 2016. Accessed December 14, 2016.
5. Durand MA, Moulton B, Cockle E, Mann M, Elwyn G. Can shared decision-making reduce medical malpractice litigation? A systematic review. BMC Health Services Research. 2015;15167.
6. Durand MA, Carpenter L, Dolan H, et al. Do interventions designed to support shared decision-making reduce health inequalities? A systematic review and meta-analysis. PLoS One. 2014;9(4):e94670.
7. Stacey D, Légaré F, Col NF, et al. Decision aids to help people who are facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014;(1):CD001431.
8. Final recommendation statement, breast cancer: screening. USPSTF website. http://bit.ly/2o44QQe. Accessed January 7, 2017.
9. Légaré F, Ratté S, Gravel K, Graham ID. Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals' perceptions. Patient Educ Couns. 2008;73(3):526–535.
10. Six tips of shared decision making. Informed Medical Decisions Foundation/Healthwise. http://cdn-www.informedmedicaldecisions.org/imdfdocs/SixStepsSDM_CARD.pdf. Accessed December 14, 2016.
11. Sheridan SL, Harris RP, Woolf SH. Shared Decision-Making Workgroup of the U.S. Preventive Services Task Force. Shared decision making about screening and chemoprevention: a suggested approach from the U.S. Preventive Services Task Force. Am J Prev Med. 2004;26(1):56–66.
12. Price D. Sharing clinical decisions by discussing evidence with patients. Perm J. 2005;9(2):70–73.
13. Caverly TJ, Hayward RA, Reamer E, et al. Presentation of benefits and harms in U.S. cancer screening and prevention guidelines: a systematic review. J Natl Cancer Inst. 2016;108(6):436.
14. Zipkin DA, Umscheid CA, Keating NL, et al. Evidence-based risk communication: a systematic review. Ann Intern Med. 2014;161(4):270–280.
15. Sinayev A, Peters E, Tusler M, Fraenkel L. Presenting numeric information with percentages and descriptive risk labels: a randomized trial. Med Decis Making. 2015;35(8):937–947.
Copyright © 2017 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact email@example.com for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions
More in FPM
Related Topic Searches
MOST RECENT ISSUE
Access the latest issue
of FPM journal