Trained for a career in doctor-patient shared decision-making
France Légaré began her master’s degree in community health around the same time that she began practicing medicine in 1990. Dr. Légaré completed her master's degree in 1995. In 2000, she began work on her doctoral degree and obtained a PhD in population health from the University of Ottawa in 2005.
How does one promote enlightened decision-making?
Dr. Légaré’s doctoral thesis addressed a relatively innovative subject: how to incite health professionals to promote enlightened decision-making by their patients.
Ethics are of course central to shared decision-making and their role in the process must inform future action in this regard. It is, however, vital to consider the advantages and disadvantages of systematically involving patients in decision-making. Decisions mark all stages of the healing process and health professionals are specialists in their field: is it really efficient for doctors to spend so much time explaining issues to patients just so that patients can become involved? This could double or even triple the duration of a doctor's appointment!
It is true that it takes more than a standard 10 minutes for a doctor to make a diagnosis, explain the issues, and give the patient time to share in the choice of treatment or care. In real life, doctors are quick to provide their patients with a prescription and tell them to come back should the problem persist. But research shows that if efforts are made to master the concept of shared decision-making, itdoesn not have to take significantly longer than the traditional model.
Dr. Légaré's doctoral studies included an applied research project that addressed the following questions: Is the patient comfortable with the treatment decision? Was the patient granted the respect due to an individual who is theoretically responsible for what happens to his/her body? Does or doesn't the patient have the right to the information necessary for an informed decision? "When faced with options, patients are not stupid", argues the researcher. "Once you help people weigh the pros and cons, including all possible risks and benefits associated with each option, they tend to choose the option that is most advantageous for their unique situation." The result is that patients are less likely to choose options that have higher risks or low potential benefits. In addition, patients have more realistic expectations about the results of treatment.
But that’s not all. Studies done in the United States suggest that shared decision-making reduces "unjustified variations in clinical practice" across territories. Why, after all, is the rate of tonsillectomy higher in one territory than it is in another, given that there is no medical justification for the discrepancy?
Shared decision-making being based on evidence is another advantage in its favor. “In the context of uncertainty, this approach limits decisional regret (…) and eventually helps reduce the risk of patients intending to sue therapists if their health deteriorates. Involving the patient in decision-making thus helps both patients and doctors feel more comfortable with the decision made”, explains Légaré. As humans, we are less likely to accuse or to lay blame for a given decision if we have participated in that decision. Furthermore, not all patients are ready to leave all decisions up to the doctor. It is important for these patients to feel at ease.
But should shared decision-making be applied in all situations? Is it as relevant to colds and to broken legs as it is to cancer treatments or to situations where the prolongation of life is at stake? To put it plainly, what does Dr Légaré mean by a relevant context of uncertainty in the area of human health? Is not uncertainty more the norm than the exception where human health is concerned?
“Clearly, this is an empirical question. I explored this in my research project and all 13 of my study groups ranked cancer treatments at the top of the list. Next came treatments involving the use of antidepressants, the level of care, changes to lifestyle habits and screening tests. So we are starting to have an idea of the contexts in which shared decision-making is most relevant”, explains France Légaré.
From her first years of studying architecture at Laval University, Légaré has pursued her dream of building (and rebuilding) society. But where she once dreamed of constructing beautiful buildings for people's well-being and a healthy environment, she now devotes herself to constructing better medical practices which, she hopes, will result in the improved treatment of patients and better medical care.
Text adapted from an interview by Daniel Allard for ITIS, Québec City, March 19, 2007.