JAMA – Shared Decision-Making in Practice


Beach and Sugarman (2019) provided an analysis of the SDM or shared decision-making framework in clinical practice, in which clinicians are encouraged to engage patients on the values and preferences of the patients.

“Professional societies and other groups generating screening and treatment guidelines specifically recommend SDM. In 2015, reimbursement from Medicare for lung cancer screening was made contingent on SDM,” the authors of the JAMA article stated.

If the values and preferences of the patients sit on morally firm foundations, then there can a more reliable process moving forward for the benefits of the patients. It respects the cultural and individual variations in values and preferences while also dignifying the independent judgment of the patient about their own health and welfare.

Even so, SDM, as a practice, is “rarely achieved in practice.” The reasons provided for this theory and practice gap is the multifactorial nature of the problem. There are many factors leading to reduced implementation of it.

“Studies show that patients tend to think they have been involved in making decisions when direct observation suggests they have not,” Beach and Sugarman reported, “This may be because patients are unaware that a decision was made, the measurement standards for observed behavior are too dogmatic, or both.”

Then the coding of the information can be problematic as well as creating an environment in which patients know their role in decisions and processes with the medical professionals.  Further time placed into the hands of the medical professionals to explain to the patients may be wasted time better spent on other medical issues or medical duties. Benefits of more time explaining remain uncertain.

The positions of the author of the paper is that SDM should be implemented in medical settings more in spite of the lack of clarity in the reportage. They provided solutions includng more specificity for the task in the calls for SDM, the use of decision aids to become more routine and available, the prioritization of decisions requiring SDM over others to increase its prevalence, the facilitation of engagement with a better interpersonal environment, and the importance of the communication models of practitioners more conducive to the independence of the patients and the giving of recommendations by the medical professionals with a modicum of prudence.

“SDM is a means to an end. The principal goals of SDM are to respect patients as individuals and to deliver care consistent with their values and preferences. Achieving these goals will sometimes involve explicitly engaging patients in decision-making. But decision-making can be emotionally demanding, and imposing a standard by which patients are expected to engage in all (or even most) decisions is not only unrealistic and inefficient, but also potentially burdensome to patients and clinicians,” the authors concluded.


Beach MC, Sugarman J. Realizing Shared Decision-making in Practice. JAMA. Published online July 25, 2019. doi:10.1001/jama.2019.9797

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