Shared Decision Making

Shared decision making ( SDM; english shared decision -making, SDM) is used in medicine interaction or communication between doctor and patient called, which aims to come to a doctor and patient together were responsible agreement on appropriate medical treatment.

Concepts of the patient - physician relationship

In the context of medical communication, a distinction different models of the patient -physician relationship, PEF seems increasingly enforce lately as a general expectancy of patients.

• The traditional paternalistic model is characterized by the authority and sovereignty sole decision of the physician. The doctor makes the diagnosis and decides on the best for the patient in his view therapy. He contains the patient unnecessary information before. Likewise, there can be a communication process, although this is structured by the functional information interests of the physician for purposes of diagnosis and optimized treatment. Not infrequently, however, the patient will also withheld information about its best to make supposedly not to express skepticism or decision conflict.

• The informative model, also known as " consumer " model is strongly influenced by " cognitivist " interpretations of the patient - physician relationship, which assume a largely affect- neutral structure of the information exchanged here. The patient is supplied by the physician with a variety of information, ranging from hypotheses about possible disease backgrounds on diagnostic findings to therapeutic alternatives with their advantages and disadvantages. The patient remains here Sovereign of the decision-making process by him may order the offered information and convert it into a decision or must. Personal experiences, needs and fears of patients are not denied here, but hidden from the patient - physician relationship.

• This taking on emotional and rational some little moments in the context of the disease experience and the recovery is, however, explicitly highlighted in the model of participatory decision-making. In addition, the interaction direction in this concept is two-pronged, doctor and patient ask and answer questions.

Core elements

The core elements of participatory decision-making, inter alia, includes a " collaborative relationship " between patient and physician with the same level of information about possible choices for a medical decision. In this case, the doctor and patient to actively and equally contribute their decision criteria in the Abwägungs and decision making process and partnership to take responsibility for the decision. Legally, however, the patient has the right to self determination.

Process steps

The participatory decision-making requires different action steps. These include

Social and scientific backgrounds

PEF is not a modernist concept of the patient - physician relationship, the different in the information society newly emerged values ​​and norms (information, participation) are blind to reality transfers in the system of medical care or even this " grafting ". As a significant and probably also future-oriented to PEF or SDM can be characterized, among other things the following reasons:

• Are available for patients - in particular by computer and the Internet - in this dimension previously unknown possibilities for autonomous procurement of health and disease information, which they use as well. Hide this (partly true, but partly also " half-baked " ) prior information of the patient, it would not be called to take seriously in order to abstract from his knowledge and related fears and desires, so to see only the disease and not the patient.

• Comprehensive analyzes of medical interventions have made ​​it clear that medical action and medical treatment decisions probably a very great extent on personal preferences or standards of value are dependent, which can not be clearly inferred from the current research and knowledge.

• Through the research results of evidence-based medicine (EBM ) has not only shown that there is no scientific evidence of its effectiveness for a variety of the common conventional medicine practiced daily therapy methods. Was furthermore demonstrated also that there is no clearly best method of treatment for a large number of diseases, the " therapeutic bullet", but that usually several options with different benefits and risks are available, can be that medically clear decision without what now is the best for the patient.

• "Compliance" as compliance with medical therapy instructions or " Concordance " as a consensus between patient and physician regarding the treatment plans depends to a very large extent on whether it actually came in the first medical consultation to an involvement of the patient questions and requests. This not only has economic importance, as shown by the estimates for prescribed, but also remote or never consumed medications. In addition, there is also evidence that information and participation of patients affects the quality of treatment and the therapy effects positive.

Empirical research results

Expectations of patients

"Until the 1980s, the majority of patients still preferred a passive role in the medical treatment process. The active and dominant role of the physician apparently corresponded to the needs of most patients [ ... ]. Today, many patients want to be involved in medical decisions [ ... ] and also the policy calls for the greater involvement and participation of patients. "

This was the conclusion of a change of patient claims pull Klemperer / Rose Wirth because of two major patient surveys. In telephone interviews with 8,119 respondents in eight European countries gave 23% of its intention to decide on the treatment, 26 % would prefer to let the doctor decide and 51 % want to decide together with the doctor about the treatment method. Survey results from the " Health Monitor" by the Bertelsmann Foundation in 9146 Germans lead to a similar result: 58 % want a joint decision, only 14% of an autonomous decision and 28 % would prefer to let the doctor decide alone. Also in the " PIA study" (patient information in general medicine ), over 1,100 patient was placed in GP surgeries of the Ruhr area, the question of the patient role, and also wants the vast majority of 77 % a participation in treatment decisions.

The position of the doctors

A survey of the " Health Monitor" shows predominantly positive judgments: 67 % are in favor of this concept, 21 % favor the sole medical decision, 8% the patients decision, 4% do this depends on the individual case. This younger doctors seem to be more open-minded for Shared Decision Making. However, more detailed inquiries also show that this overall positive vote is penetrated to a considerable degree of skepticism and discomfort and is rated at least ambivalent. When asked what effect it has when patients have already informed before the doctor's appointment on complaints, treatments, etc., shows up about two- thirds of the " Health Monitor" surveyed 500 doctors attest that these patients have "high self-interest " and almost half experienced by facilitation of their work. Also, almost half of the patients, however, takes this information notice as additional encumbrance and around 40% discredit the patient's knowledge as " a mixture of more or less relevant or useful information, which only hinder me. " Almost a third of doctors are also derogatory judgments, as such, that 's information patients would only confuse them or as physicians usually lack the time to go into it.

Effects

Shared decision making has generally positive effects on treatment adherence (compliance), on the treatment success and patient satisfaction. It remains, however, that the patient ultimately and legally alone decides whether an intervention or other treatment is performed or not ( self-determination of the patient).