Shared decision-making is more than asking what patients want

Medical students are sometimes surprised that we don’t always follow the guidelines they have learned in medical school and instead use the patient as our guide when making decisions. Shared decision-making involves exploring patient preferences and what is important to them.

This sounds obvious but it’s actually not easy. As I said before in this blog post, I’m not sure I can always answer the 5 Choosing Wisely ‘questions to ask your doctor’, which form the basis of shared decision-making.

Apparently many doctors believe they already do this when they don’t. For example, a survey of US-based health practitioners observed high confidence in the face of limited understanding. There are many myths about shared decision-making (the 2-minute video below explains the most common ones).

Shared decision-making is more than asking what a patient wants. It also includes providing information about the pros and cons of available options, including the level of evidence around risks and benefits of tests and treatments. If I and many of my colleagues find this challenging, how do patients experience it?

Why our opinions get us in trouble

“The history of human opinion is scarcely anything more than the history of human errors,” Voltaire said a long time ago.

Health professionals are trained to give opinions. It’s what we do every day in caring for our patients and leading our teams. Sometimes, however, it’s better not to give an opinion – or at least sit on it for a while.

Admittedly this is not always easy to combine with busy clinics, fast-paced lifestyles, opinion-based social media and rapid news cycles.

Nobel Prize winner Daniel Kahneman described two ways of thinking in his well-known book ‘Thinking, Fast and Slow’.

The first method, which he called system one, is fast, intuitive, runs automatically and cannot be switched off. It generates first impressions and intuitions based on experience. It is however subject to errors and biases and is poor at performing statistical estimates.

The second way of thinking, referred to as system two, takes more conscious effort and time. It is normally in low-effort mode but when system one runs into difficulty, system two will be engaged.

The two systems can work effectively together, as long as we are aware that our first guess, based on system one thinking, may not always be right and that we need to verify it by applying more analytical system two thinking.

The challenge, as I see it is, to have an opinion and an open mind at the same time.

This is an edited version of an article originally published on NewsGP.

Critical thinking in your team

Some time ago I was at a meeting with a great team of doctors and managers. We wanted to solve a particular difficult problem. The issue was discussed at length and we decided to invest time and money to improve the situation. Months later our group’s solution turned out to be a failure. We looked at each other in disbelief and asked: Why didn’t we see this coming? Did we really make this poor decision?

There are many advantages to working in a group or team, but there are also risks. When we’re in a group we often tend to avoid conflict and follow the leading opinion. This ‘groupthink’ phenomenon has lead to many historic disasters such as  the explosion of the Space Shuttle Challenger and even the Vietnam War. Groupthink stops critical thinking and may lead to an unhealthy decision-making process. It can happen everywhere, including social networks such as Facebook and Twitter where group loyalty or group pressure may prevent airing of alternative ideas.

Last week I was watching World War Z. In this movie Brad Pitt fights the latest pandemic: a zombie apocalypse. Ten days before the pandemic is in full swing an intelligence report mentions the emergence of zombies. “Zombies? You’ve got to be kidding me,” was the response. The report was dismissed. Except… in Israel, where the intelligence service followed the ‘tenth man rule’: when nine people agree, one person – the tenth – has to prove them wrong. In the movie this person convinced the Israeli intelligence service to prepare for a zombie war – and Brad Pitt of course finds a way to save the world.

I’m not sure if the tenth man rule is real or not, but in World War Z Israel implemented this decision-making model because the Jews had been caught out too many times in history, for example during the Second World War and the Yom Kippur war. The signs on the wall were ignored by decision makers, and Israel was determined not to let this happen again. Read more in this excellent post: What World War Z Can Teach You About Critical Thinking.

There are many other ways to make better group decisions, such as looking at the risks of each decision or wearing different thinking hats. A good chair encourages critical thinking. Researchers have suggested ways to avoid groupthink. Here are 8 useful tips from psychologist Irvin Janis (borrowed from this article):

  1. Leaders should assign each member the role of ‘critical evaluator’. This allows each member to freely air objections and doubts.
  2. Leaders should not express an opinion when assigning a task to a group.
  3. Leaders should absent themselves from many of the group meetings to avoid excessively influencing the outcome.
  4. The organisation should set up several independent groups, working on the same problem.
  5. All effective alternatives should be examined.
  6. Each member should discuss the group’s ideas with trusted people outside of the group.
  7. The group should invite outside experts into meetings. Group members should be allowed to discuss with and question the outside experts.
  8. At least one group member should be assigned the role of Devil’s advocate. This should be a different person for each meeting.

How does your team encourage critical thinking?