Shared decision making

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.
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.
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.
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.