Modern healthcare grew from a paternalistic model, which simply put, means providers make healthcare decisions for patients. Paternalism is based on an underlying assumption that providers are the most capable of making decisions that generate the best clinical outcomes. An example of paternalism is when clinicians recommend a treatment and ask patients for consent. In this theoretical example, patients have only the choice to consent or decline a single treatment option chosen by the doctor.
In contrast to paternalism, person-centered care emphasizes that healthcare should account for unique and complex patient factors. Though definitions vary, the most important element in person-centered care is shared decision making.(1) An example of person-centered care is when clinicians offer different therapy options, explain details about each option, and ask patients for their thoughts and choices. The four steps comprising shared decision making are:(2)
- Informing a patient that both a decision is needed, and their opinion is important.
- A description of the options with their associated pros and cons.
- A discussion encouraging dialogue about what is meaningful to patients (e.g., preferences).
- A discussion of decision-role preference, followed by decisions to decline, defer, move forward, etc.
The ideas of shared decision making are rooted in ethical concepts such as the idea that all people are entitled to freedom of choice. Other key concepts are reflected in expectations that providers should express certain behaviors consistent with shared decision making.(3) Those behaviors include:
- Sharing knowledge about a condition and treatments in understandable terms.
- Considering patient views and preferences seriously.
- Recognizing patient individuality.
- Seeking to understand the physical and emotional experience of a problem.
Concepts vs. Practice
Practicing shared decision making isn’t necessarily automatic. A recent study among medical residents reported that even though they supported shared decision making concepts, most didn’t engage in shared decision making with patients.(4) Why? Medical residents valued their professional responsibility to provide the “best” care. They reasoned that including patients in care decisions would negatively affect this responsibility because patients might choose substandard care. Therefore, providing the “best” care required paternalistic decision making. Time pressures and poor confidence in guiding a shared decision making process were other reasons cited. This research suggests that successfully engaging in shared decision making likely demands training, practice, a compatible professional identity, and perhaps other factors.
Choice as a Therapeutic Tool?
An article in the journal Annals of Behavioral Medicine offers a new perspective.(5) The authors reviewed and analyzed data from 15 studies from a relatively new field of research on “placebo” effects. Placebo has historically referred to something with no true clinical effect, but with a potential to influence a false perception of improvement. However, placebo is now recognized as a potentially valuable therapeutic tool that produces authentic and beneficial effects (also referred to as non-specific) for a wide range of conditions.
While the exact mechanisms explaining how placebos produce their beneficial effects are not fully understood, research is ongoing. One way to think about placebo effects is to recognize that all treatments, including manual therapies, are influenced by numerous contextual factors. Instead of being inert, the environments in which treatment occurs, and other factors like doctor-patient relationships, can influence clinical outcomes. For example, these contextual factors can potentially modify pain processing in the central nervous system.(6,7)
Summarizing the body of research in this area, the authors report that when people are given a choice of treatments, placebo effects (i.e., authentic, rather than perceived, clinical effects) are enhanced. Thus, offering patients treatment options can potentially improve clinical outcomes. However, more research is needed to answer questions like: How does this research translate to chiropractic clinical settings? What choice factors most influence effectiveness?
A Way Forward
There is little research on shared decision making in the field of musculoskeletal health. In concept, shared decisions should result in more effective care. But currently, little is known about how shared decision making relates to clinical outcomes.(8) Despite this information gap, there are compelling ethical reasons to support shared decision making. First, engaging in shared decision making is a practical application that demonstrates respect for the autonomy of each patient. Second, fostering shared decision making recognizes each patient as an individual, by valuing opinions, goals, and preferences. And third, offering choices inherently acknowledges that we as providers don’t fully understand what is “best” in every situation.
Systematically engaging in shared decision making with patients may require asking ourselves introspective questions like:
- Do I consciously or unconsciously carry the full responsibility for choosing the “best” care plan.
- Am I comfortable supporting reasonable care plans chosen by patients over my preferred methods?
- Do I offer true options and encourage dialogue about patient concerns, preferences, etc.?
- Do my report of findings, treatment recommendations, and consent process reflect a paternalistic or person-centered approach?
It is important to recognize we are all human. All providers exist somewhere on a spectrum with person-centered care at one end and paternalism on the other. With any given encounter, we may shift one way or another. Regardless of where we are at any given point, constantly striving to move closer to the person-centered end is a worthwhile endeavor.
Dr. Vining is associate dean of clinical research, as well as a professor, at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic, in Davenport, Iowa.
References
- Barry MJ, Edgman-Levitan S. Shared decision making–pinnacle of patient-centered care. N Engl J Med. 2012 Mar 1;366(9):780–1.
- Stiggelbout AM, Pieterse AH, De Haes JCJM. Shared decision making: Concepts, evidence, and practice. Patient Educ Couns. 2015 Oct;98(10):1172–9.
- Bendapudi NM, Berry LL, Frey K a, Parish JT, Rayburn WL. Patients’ perspectives on ideal physician behaviors. Mayo Clin Proc Mayo Clin. 2006;81(3):338–44.
- Driever EM, Tolhuizen IM, Duvivier RJ, Stiggelbout AM, Brand PLP. Why do medical resideDrnts prefer paternalistic decision making? An interview study. BMC Med Educ. 2022 Mar 8;22(1):155.
- Tang B, Barnes K, Geers A, Livesey E, Colagiuri B. Choice and the Placebo Effect: A Meta-analysis. Ann Behav Med Publ Soc Behav Med. 2022 Oct 3;56(10):977–88.
- Bialosky JE, Beneciuk JM, Bishop MD, Coronado RA, Penza CW, Simon CB, et al. Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. J Orthop Sports Phys Ther. 2017 Oct 15;48(1):8–18.
- Bialosky JE, Bishop MD, Penza CW. Placebo Mechanisms of Manual Therapy: A Sheep in Wolf’s Clothing? J Orthop Sports Phys Ther. 2017;47(5):301–4.
- Tousignant-Laflamme Y, Christopher S, Clewley D, Ledbetter L, Cook CJ, Cook CE. Does shared decision making results in better health related outcomes for individuals with painful musculoskeletal disorders? A systematic review. J Man Manip Ther. 2017 Jul;25(3):144–50.
