A personal perspective on shared decision making

Dr Dave Tomson is a GP in North Tyneside and is the primary care lead for the Health Foundation’s MAGIC programme.

The project aims to embed shared decision making into everyday clinical practice within primary care in the North East. Here he talks about how shared decision making has influenced his own practice and improved patient experience.

A life-long interest

The doctor–patient relationship has always fascinated me. Doctors can do so much good, but there’s also so much potential for harm – either physically, or by taking away control from the patient.

I’ve always tried to make sure I give back, or at least share, that knowledge and control. As a GP I don’t want to be doing things to people, I want to be working with them. Shared decision making fits really well with this ethos as it’s all about collaboration.

I’ve been practising elements of shared decision making with my patients for many years, but being involved in the MAGIC programme means I’m improving the quality and frequency of its use, while also encouraging other clinicians to work differently.

Better communication

Finding ways to effectively communicate with patients is always the most challenging aspect of my work, but shared decision making helps to give a much better structure to my consultations. When there are decisions to be made I make sure that I signpost choices, take time to explore options, and find out what matters to the patient.

There are certain phrases I use a lot these days, like 'so, how do we make a decision that is right for you?', and, 'would it help to go through the options and look at the pros and cons?' Asking those questions has a big impact.

If available I’ll use decision support materials to help explain different options and as a prompt to talk around the issues. These are very useful. We have about 20 in our practice now, covering everything from heavy periods to carpal tunnel.

All of this ensures we arrive at a decision about treatment or screening that is informed both by medical evidence and by the values and preferences of the patient.

I’m happy when I know I’ve done a better job than I used to and when I can see that patients are more engaged. It’s very satisfying, and I suppose it’s part of my ongoing quest to be a good doctor.

The right to ask questions

Most patients I see welcome being more involved in decisions about their care, as this quote suggests:

'When I go to the doctor with a simple thing I’m really comfortable if he says, "this is the best way to treat it". If it’s something more complicated... I would be happier if I had the full facts and figures in front of me, all the various options, and that we would have plenty of time to come to a decision together on the best way forward.'

Some of my patients helped us put together this short video which encourages other patients to ask questions about their treatment options and to expect a more collaborative approach from their clinician. It’s great to hear their positive experiences of sharing decisions about important aspects of their care.

Patients also explain why in the past they haven’t felt able to ask questions during a consultation. Reasons include feeling embarrassed, feeling lost in too much information, and not knowing what questions to ask. One lady explains: 'People don’t ask questions of their GP or nurse because they don’t feel they have the right to ask...'

Part of the challenge is about changing this assumption. Some patients do find it difficult to move from a passive to a more active role and there will always be some who say, 'oh I don’t know doc, you decide'. But at least they’ve been given the opportunity, and if I’ve taken time to discuss their preferences then I can guide them towards an informed choice.

The challenge ahead

Our challenge is to try and incorporate shared decision making into everyday clinical practice. This means changing systems and culture in the NHS, while also convincing clinicians and patients to change their behaviour.

As the lead for MAGIC in primary care, it’s been great to see the introduction of the decision support tools we’ve developed to all the GP practices involved. These are now listed on the Patient UK website (click on the 'treatment options' tab) and are being very well received.

But there are still lots of hurdles to overcome. Some doctors think it will take up extra time, or don’t yet have access to the right data and decision support materials. They might need to develop new skills. Getting clinicians to work differently isn’t easy. But I’m proud of the training we’ve done and the interest this has generated.

We encourage clinicians to think from the patient’s perspective, or to imagine how they would feel if they were told they needed an operation – what questions would they like to ask? Their patients are no different.

It’s great to watch the individual breakthrough moments when you can see clinicians 'get it'.