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Am Fam Physician. 2022;106(2):205-207

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

• Shared decision-making can be optimized when organizations provide resources and establish a supportive culture.
• Offer patients resources to prepare for important discussions and prompt goal consideration and questions for the clinician.
• Ask patients to teach back concepts to check their understanding.
• Document decisions and underlying reasons and share details with the patient and health care team.
From the AFP Editors

Shared decision-making between physicians and patients is a vital component of effective health care. Shared decision-making can improve patient experience and satisfaction, increase trust, and improve understanding of the risks and benefits of available options. The National Institute for Health and Care Excellence (NICE) published guidelines to offer practical advice for incorporating shared decision-making into everyday encounters.

An Organizational Change

Shared decision-making is an ongoing process that includes multicomponent interventions, which are more effective than single encounters.

Qualitative studies and expert opinion encourage strong organizational leadership to positively influence the use of shared decision-making through available resources and organizational culture. The use of influencers or champions within teams should be considered to enhance implementation in a practice. A shared decision-making implementation checklist provides an effective framework for champions to influence change at their institution (https://www.england.nhs.uk/publication/shared-decision-making-summary-guide).

Implementation

Family physicians can engage patients in shared decision-making throughout stages of care by using specific techniques in conversations before, during, and after medical discussions.

BEFORE THE VISIT

Physicians should encourage shared decision-making with patients before the encounter. Studies showed an increase in patient knowledge and satisfaction from offering patients resources in advance of encounters to prepare for important discussions. This might include prompting to consider their goals for care and for the discussion, and questions for the physician.

Some patients benefit from the support and presence of another person during the health care visit, such as a family member, friend, or caregiver. These people can serve as advocates who can reinforce understanding, empower participation in shared decision-making, and provide reassurance. Although not every patient will wish to participate in decision-making or to have decisions made with or by family members, every patient should be given the opportunity to choose the degree to which they would like to participate.

DURING THE VISIT

NICE recommends the use of evidence-based models to enhance shared decision-making in clinical practice. The three-talk model is a shared decision-making framework with strong supporting evidence for all of the components. Specifically, the stages include team talk, option talk, and decision talk, and they help clinicians structure the shared decision-making process during the visit.

Team Talk. Team talk occurs at the opening of a discussion when patient autonomy and preference are introduced and collaboration between the patient and physician is emphasized. Team talk establishes a supportive environment where the patient can express what matters most to them and share their preferences and goals of care.

Best practices during team talk include agreeing on an agenda at the beginning of the visit to prioritize topics and include how long the discussion will last. During team talk, time should be set aside to answer questions following the discussion.

Option Talk. In option talk, treatment options are compared based on the risks, benefits, and consequences. Discussions should consider the context of the patient's preferences and goals. The option of no treatment should be addressed routinely. During the discussion, the clinician should ensure that the patient's treatment goals are understood by all, and that any misconceptions are addressed.

If available, numerical data should be used to describe risks and benefits when available instead of terms such as rare, common, or uncommon. Risks and benefits should be framed positively and negatively, such as “This adverse effect occurs in one out of 10 people, so nine out of 10 people do not experience this effect.” Table 1 lists recommendations for effectively communicating risks and benefits. Risks can be presented using infographics containing numbers and pictures to display positive and negative effects together. Patient decision tools reliably enhance patient understanding if they are quality-assured and relevant. Quality clinical support tools are discussed in a standards framework from NICE (https://www.nice.org.uk/corporate/ecd8).

RecommendationDiscussion points
Use a mixture of numbers and picturesNumerical rates with pictograms or icon arrays
Positive and negative framing at the same time
Use numerical data to describe risksTerms such as risk, rare, unusual, and common can be interpreted in different ways
Use absolute risk rather than relative riskRisk of an event increases from 1 in 1,000 to 2 in 1,000, rather than the risk of the event doubles
Use natural frequenciesUse numerals (10 in 100) rather than percentages (10%)
Be consistent when using data; use the same denominator comparing risk7 in 100 for one risk and 20 in 100 for another, rather than 1 in 14 and 1 in 5
Present risk over a defined period of time (months or years)If 100 people have treatment for one year, 10 will experience this adverse effect
Use positive and negative framingTreatment will be successful for 97 out of 100 people, and it will be unsuccessful for 3 out of 100 people

Patient understanding should be verified regularly when sharing options. Teach back, or asking patients to explain concepts discussed, confirms that they understand the information being discussed. The chunk and check technique provides smaller chunks of information and confirms patient comprehension before moving on.

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Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, contributing editor.

A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide.

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