Wednesday, May 15, 2013

Shared decision making

(The following was originally posted on the The AFP Community Blog on 4-22-13.)

Let’s say you’re seeing a healthy 21-year-old woman in your office for contraception management.  She takes no other medicines, has no personal or family history of blood clots, and has no contraindications to estrogen.  She is interested in a long-acting contraceptive that she won’t have to worry about remembering every day.  IUD, subdermal progesterone implant, q 3 months injectable progesterone – how do you choose?

Or, how about this: a 45-year-old man presents with frequent migraine headaches.  You review the best evidence for migraine prophylaxis in adults and are stuck deciding between propranolol and amitriptyline.   Which do you use?

Gray areas like these abound in Family Medicine, even with the ever-growing primary care evidence base.  In both of these scenarios, no one option is clearly superior to the other.  All of those contraceptive options would be efficacious for the 21-year-old woman, and, likewise, the efficacy of propranolol versus amitriptyline for the migraineur is probably a toss-up.

These types of situations, where multiple reasonable treatment options exist, provide an opportunity to involve the patient in the decision.  Shared decision making (SDM) brings the patient’s preferences into the conversation and gives them some ownership over the final choice. 

I wish that I could tell you that SDM has a rigorous evidence base behind it, but like many behavioral interventions, few quality studies exist to suggest patient benefit.  A study last week in the Annals of Internal Medicine, however, may help to reinforce SDM’s value.  Weiner et al engaged patients who surreptitiously recorded their office visits with Internal Medicine residents.  The residents who adapted their care plan to meet their specific patient’s preferences had, in return, improved compliance from their patients. 

This study was small and needs to be replicated in bigger settings, but its finding makes intuitive sense: patients invited to be involved in treatment decisions tend to have better adherence with those treatments.  

You can ease the loss of the extra time it takes to do SDM by billing for the time spent in counseling (10 min = 99212, 15 min = 99213, and 25 min = 99214).  Just be sure to document as such in your encounter note.

In 2010, AFP also published a nice SDM review, along with a helpful framework for the office.  You can find that Curbside Consultation here:

I welcome your thoughts on the practical use of SDM in the busy family doc’s practice.  


  1. SDM often reminds me of a psychological tactic employed to get kids to eat their vegetables. Rather than saying "eat your broccoli," you say "Which would you rather have--broccoli or carrots?" The kid will feel ownership of the decision and take an active role in complying (or... adhering) to the request.

    I think SDM is a scaled-up version of this technique, but instead of trickery it's patient empowerment

  2. Nicely described about decision making. I have learnt about it in my college. It is helpful every people in this living world. And you have explained about it in brief .Currently I am working with Ian johnson infinite group .where I taught about such kind of topics like decision making and team management.