Richard Thomson talks with
ScienceWatch.com and answers a few questions about
this month's Fast Moving Front in the field of
Article: Patients' preference for involvement in
medical decision making: A narrative review
Authors: Say, R;Murtagh,
Journal: PATIENT EDUC COUNS, 60 (2): 102-114 FEB 2006
Addresses: Univ Newcastle Upon Tyne, Sch Med, Sch Populat
& Hlth Sci, Framlington Pl, Newcastle Upon Tyne NE2
4HH, Tyne & Wear, England.
Univ Newcastle Upon Tyne, Sch Med, Sch Populat & Hlth
Sci, Newcastle Upon Tyne NE2 4HH, Tyne & Wear, England.
Why do you think your paper is highly
It is commonly the case that there is more than one option for treating a
particular condition or problem, with different options having different
risks and benefits. The choice between options may thus be sensitive to
patient preferences. A good example is the choice that women with breast
cancer may face between mastectomy and breast-conserving surgery.
Modern healthcare is increasingly moving towards engaging patients in
decisions about their own treatment, where such preference-based choices
exist. However, engaging patients in such decisions is challenging for both
clinicians and patients. In fact, patients themselves vary in their desire
for involvement in treatment decisions; some wish to be actively involved,
others prefer to leave the decision to their doctor.
Does it describe a new discovery,
methodology, or synthesis of knowledge?
"...one of the biggest challenges is
the implementation of shared decision-making
and decision support in routine practice,
appropriate to the particular
Before our review of the literature, studies undertaken across the world
which sought to understand the factors that influence patients' preferences
for being engaged in decision-making had not been systematically reviewed
and summarized. This systematic review included analyses of both
quantitative and qualitative studies in order to summarize the key features
associated with patients' desire to engage in treatment decisions.
In all, from an extensive literature search, 33 studies were included in
the review, covering a wide range of patient groups and clinical settings,
from patients in primary care through to patients with specific diagnoses
such as cancer.
Would you summarize the significance of your
paper in layman's terms?
We have demonstrated that there are several key patient factors that are
consistently associated with patients' desire to participate in their own
treatment decisions. Younger, better-educated patients and women generally
prefer a more active role in decision-making than older, less educated
patients and men. In addition, patients' desire to be involved in treatment
decisions may develop and change over time as they proceed through their
Features associated with the type of decision and of illness are also
likely to be important. For example, it may be more difficult for patients
to be involved in making decisions about illnesses with which they are
unfamiliar. Furthermore, past experience of health care and the
relationship of the patient with their clinician are important, although it
is unclear whether the decision-making style of clinicians affects
patients' preferences or whether patients actually seek out clinicians
whose style matches their own preference.
Overall, there is a wide distribution of patient desire for engagement in
treatment decisions and it is important that clinicians are sensitive to
this. Even if certain types of people or certain types of decisions are
associated with less desire for engagement, there will still be some
patients in this situation who wish to be actively engaged. The only way
this can truly be assessed is if clinicians and patients explore these
preferences at an early stage, such that patients can be offered
appropriate engagement, and this should be kept under review in case the
How did you become involved in this research
and were any particular problems encountered along the way?
I became involved in risk communication research and patient
decision-making as a result of research into decisions about patients with
atrial fibrillation—irregular heart beat—who are at an
increased risk of stroke. We sought to develop guidelines that incorporated
patient perspectives. However, as we worked through this, it became clear
that the best way to decide on appropriate treatment for a patient where
there are real choices between alternative treatments could only be
achieved by truly engaging the patient.
This is complex and requires an understanding of how to communicate risk
and how to ensure that a patient is well-informed, that their values and
preferences are explored, and that they are able to make a decision that is
consistent with their values and preferences. From that initial interest
has grown a program of work which focuses on
risk communication and shared decision-making in
Where do you see your research leading in the
"A good example is the choice that
women with breast cancer may face between
mastectomy and breast-conserving
There is a strong evidence base that patients who are supported with
patient decision aids are better informed; more likely to engage in
decisions, more satisfied with their decisions, more likely to make
decisions consistent with their values and more likely to comply with any
treatment decisions made. Engagement of patients more widely in their care
leads to better outcomes. Despite this evidence, true patient engagement in
decision-making remains limited and unsupported in practice.
Hence, one of the biggest challenges is the implementation of shared
decision-making and decision support in routine practice, appropriate to
the particular decision. This requires research to understand the factors
that influence this implementation and it also requires research into
shared decision-making in day to day practice. We are seeking first to
understand the nature of decision-making where patients have treatment
choices, such that appropriate decision support can be developed and
provided, as well as developing research into how best to support
implementation in actual practice.
Do you foresee any social or political
implications for your research?
Key international commentators and experts in the field have pointed out
that there is a shifting policy and research framework that is bringing
shared decision-making and patient engagement to the fore in modern health
services. They have described a "tipping point" which might facilitate
wider acceptance and implementation of shared decision making in day to day
practice (O’Connor, A.M., et al., "Toward The ‘Tipping
Point’: Decision Aids And Informed Patient Choice," Health
Affairs 26: 716-25, 2007). At the same time, healthcare services are
increasingly developing such policy; for example, the NHS in the UK has
recently restated its constitution including a commitment to engaging
patients in decisions.
Richard Thomson Professor of Epidemiology and Public Health Institute of Health and Society Medical School University of Newcastle upon Tyne Newcastle upon Tyne, UK Web