February 2000 Bulletin

Shared decision making–a new partnership

Managed care has provided a "wake-up call" to both the patient and the physician. It has enlightened both the caregiver and the recipient of the importance of their mutual relationship. By intervening in decision-making, managed care has highlighted our shortcomings more clearly for both the physician and the patient. We both are recognizing that the paternalistic relationship of the past must evolve into a more healthy partnership. Partners achieve goals by working together, utilizing mutual respect for each other’s abilities and skills and combining each other’s resources to achieve the best possible outcome.

Often we, as physicians, fail to recognize the expertise that patients bring to the table. Today’s patient is very informed about his particular illness, as well as the social situation, and knows his own behavior patterns, habits, preferences and values. We, in contrast, know the etiology of the disease, possible preventative measures, prognosis and treatment strategies. Overlooking the resource of our patients limits us to utilizing only half the tools available to assist in their care.

Materialistic consumerism in the ‘80s and ‘90s encouraged patients to make demands for better and less expensive health care, but failed to emphasize mutual responsibility. This served to widen the gap between patient expectation and the cost for available medical services, and opened the door to managed care and its resultant outcome.

Both the physician and the patient are now aware that consumerism must be brought to an end, and only through mutual understanding of the patient-physician partnership can past mistakes be rectified. It is now time for both of us to share responsibility for treatment of a disease and strengthen the patient-physician bond that has been ignored in the past. We both have to learn the value of shared information and shared decision-making.

We, as physicians can no longer ignore the alternative therapies that our patients are finding outside of our offices (e.g., World Wide Web) and we are obliged to find out whether these alternatives would be appropriate or inappropriate for the patients’ care and why. Our patients need to know more about treatment options, outcomes and limitations of medical care. Encouraging informed choices and sharing responsibility will, hopefully, help keep health care costs down.

It will become an enormous challenge for us as physicians to transform the nature of the relationship between our patients and ourselves and share the responsibility for making decisions for our patients. Older patients, and especially patients with serious illnesses, often prefer to leave the decision to the physicians, while the emerging new generation will be much more critical of physician paternalism. It will be a communications challenge for us to ascertain which patients prefer a more passive role as opposed to making choices and having a part in decision-making.

Your Academy has made the commitment to help you with these challenges by the establishment of a Council on Communications, and the launch of a web site to help you and your patient bridge this communications gap and aid your shared partnership. Through this cooperative effort, we will ultimately triumph over the interference from managed care.

Robert D. D’Ambrosia, MD


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