Shared decision making

Different types of doctor patient relationship

It is often said that relationships between patients and doctors have changed dramatically over the last 50 years. In the 1960s it would have been rare for a patient to question their doctor’s advice, now a more equal relationship is more common, However There remain some cultural and individual differences in this expectation, for example some people( doctors and patients!) still may perceive the doctor to be a figure of authority, whom it is not appropriate to challenge.
Patients with long term conditions such as diabetes, high blood pressure or epilepsy are now often encouraged to monitor and manage their own health with support from specialist nurses and other health professionals. This has coincided with changing attitudes to doctors and other professionals, easier access to information about health, a tendency for people to see themselves as consumers of healthcare (rather than patients), growing use of complementary approaches to health and acknowledgement that service users have a right to guide how publicly funded health services are run. The ageing population and increase in long term health problems also mean that if patients do not take a greater role in managing their own health conditions, existing health systems may be unable to cope. The following clip describes a patient’s wishes that this is also complemented by having the time to have conversations with health care professionals and to have the time to ask questions.

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Some branches of specialist care, for example antenatal care, women’s health and HIV, have led the field in encouraging a collaborative approach. This is evident in some of the comparisons people made in our interviews. For example a man who had become used to a more collaborative approach to treatment decisions with his HIV consultant remarked on the very different ‘old school’ approach of an oncologist. 
In this section we show a range of approaches to the patient/ doctor relationships, which we illustrate with examples from people who have consulted for a wide variety of health issues, from pregnancy to end of life care.

The strongly directive approach

This approach was very familiar to some of the older people we interviewed, who commented that when they were younger they would never have dreamt of questioning what the doctor advised. People sometimes valued this approach and suspected that many others do not really appreciate being asked to make choices about healthcare.

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Sometimes there is little uncertainty about the best course of treatment and the doctor feels justified in giving a very clear steer. A woman with breast cancer told us that she had hoped that she would be able to have the lump removed but her surgeon told her that would not be sufficient and they she needed to have a mastectomy. She trusted his advice.

There are also occasions when people prefer to be told what to do: sometimes the burden of having to weigh up different options is too great, especially when the consequences may be serious or one is feeling too unwell.

One of the problems with a very directive approach is that if the side effects are very unpleasant or the treatment does not go as planned the patient can be left feeling that they were poorly advised, or at least unprepared for the consequences.
Another disadvantage of a very directive approach is that it can undermine confidence in medicine if the patient discovers that doctors disagree. If doctor acknowledges that there is uncertainty about which treatment is best the patient is less likely to be alarmed if they find out that another doctor would have advised them differently.

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The protectively paternalist approach

‘Paternalist’ literally means ‘like a father’ which can sometimes conjure up an image of a stern authority figure but it can also suggest kindness, protection and strength. As noted above, some people appreciate a directive approach in some circumstances. It can be a relief to patients who are unable, or prefer not to, take responsibility for a decision.
When this type of consultation is handled appropriately the patient can feel cared for, protected and shielded from an unbearable or worrying responsibility.
Cultural and religious factors can also play a role in how people respond to advice from a professional. A woman who is an Orthodox Jew explained that she would always accept advice from her Orthodox Jewish doctor.

A doctor may be able to help someone to make a decision that they do not feel happy with by putting the decision in perspective. Rose’s GP pointed out that if she took HRT for a few years it could help her to deal with a difficult phase in her life and there was no obligation to stay on it long term.
The supportively directive approach

Examples of an approach that combines support with direction were seen in cases where it was clear that the doctor had little doubt about what the patient should do but still took the time to listen to their concerns and provided reassurance and guidance. 
This approach sometimes includes a doctor being willing say what they themselves would do (or had done) in similar circumstances. A man with prostate cancer was given three treatment options by the surgeon and made his decision after asking the surgeon what he would do himself. There were also several examples of doctors using this approach in helping parents to make their decision about childhood immunisation.
Negotiation

In this style of consultation the agenda may be set by either the patient or the doctor, who may debate or discuss the options and persuade each other of their views. Some of the women we talked to had expected they would need to fight to get a prescription for HRT for their menopausal symptoms and were pleased when the GP was ‘reasonable’. 
When handled well a negotiation can defuse potential conflict. GPs who want patients to reconsider a request for antibiotics for a virus, or an unnecessary referral or test, may find it more productive if they write the prescription, as requested (so that it is clear to the patient that they are not being denied what they want) but then introduce the reasons why they would like the patient to think about it further before filling the prescription or taking up the referral.
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Sometimes the negotiation stems from conflict between the doctors ideas about what the best treatment is, and the patients experience of that treatment. The following clip describes a woman’s sense that even as a teenager both she and her consultant had to “be strong” in their discussion.

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As the following two examples from people with serious and life-threatening illness show, this approach is not limited to people who are dealing with low level or long term problems.
The supportively self-directive approach

In this type of relationship it is clear that the patient, or carer, needs to make the decision but the health professionals do not leave them to feel that they are entirely on their own. Health care decisions that involve choices based on values, or those that involve other people’s health, may be dealt with this way (see ‘Decisions involving values and difficult personal choices’).
A woman who had been told that her husband was very poorly in intensive care was grateful that the hospital kept her well informed and that they warned her that a point might come where further treatment would be futile.
Treatment choices in prostate cancer are notoriously difficult. One man was given an American video which outlined the various options, including the potential benefits of delaying active treatment. He was not keen to have a treatment that might damage his sexual function and continence. Another important factor was the considerable inconvenience of repeated hospital visits for his radiotherapy.

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Sometimes people come to the conclusion that they are most likely to get the treatment that is best for them, or the person they care for, if they find out about it for themselves. Those who found that they were able to develop a supportive alliance with their doctor or practice appreciated their input and were often realistic about what they could expect.
A self-directed, or consumerist approach

This approach is at the opposite extreme from paternalism. People who take a self-directed or consumerist approach to health care assume far greater responsibility for their health decisions than any of the other approaches discussed above. This approach involves considerable commitment from the patient, yet there is evidence of this approach in a wide variety of health conditions, from life threatening cancer, through serious long term conditions such as HIV and diabetes, elective surgery, women’s health and immunisation decisions.
Some people, like the following woman who was treated for ovarian cancer, explained that they had had to battle for treatment with health professionals who thought that they would be unlikely to benefit.

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People who use health and social services, and their family carers, are encouraged to explain their needs and contribute to their care planning. There are many different ways that people can choose to become involved but sometimes their preference for services are not available. 
In contrast however, the following clip describes how positive this young woman found being involved in her care planning.
People who are able to plan for their treatment, such as elective hip replacement surgery, have the opportunity to find out about different approaches and perhaps choose treatments that are not offered by their local surgeon. One woman explained that the surgeon at her local hospital seemed content to accept her preference for treatment elsewhere because, “He just felt that I’d made up my mind, so what was the point of talking to me about his alternatives?”
People who said they had taken a consumerist approach did not say that they regretted doing so, although there was a suggestion that it might sometimes be difficult to back out of these decisions. For example a woman with breast cancer who quickly opted for a mastectomy had started to wonder if this was the best treatment for her by the time she had the operation, but still went ahead.

What if the patient makes what the doctor thinks is a bad decision?

Without good communication patients who are left to make their own decisions can feel as if the doctor has abdicated professional responsibility. However, there is some research evidence, based on observations in clinics, that doctors find ways to avoid letting people make decisions that they think are misguided. There is some evidence of this in an interview with a woman who had initially decided that she did not want to have chemotherapy, but the oncologist treating her persuaded her that she should.
Another woman was perplexed when her surgical team gave her the option of whether to have a hysterectomy but looked relieved when she decided to do so. She wondered what the team would have done had she decided against a hysterectomy – would they have told her she had made the wrong choice?
Conclusion

One way of looking at the different types of patient/ doctor relationship is to see the strongly directive or paternalist approaches as ‘old fashioned’ and the more equal partnership approaches as modern. However, people we have talked to over the last ten years, facing many different health issues, described a range of preferences from a directive, ‘doctor knows best’ model through to a completely consumerist , self-determined model where the patient relies on their own resources to make treatment decisions.

People’s preferences about consultation style are not static and are likely to change in different health conditions. A successful relationship between a patient and a health professional may include elements of different approaches at different stages of an illness, even within a single consultation, and in different health conditions.

Last reviewed February 2016
Last updated February 2014

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