Shared Decision-Making or Collaborative Practice: Importance in the Current Climate

Physiotherapy takes pride in being a profession founded on scientific research and evidence-based practice. Encouraging patients to participate more actively in the decision-making process enables shared decision, allowing the application of research to practice and promoting patient-centered care. In a collaborative process called shared decision making, patients and healthcare professionals weigh the pros and cons of each option, also taking into consideration the patient’s values, preferences, and unique circumstances. This process enables health professionals to make decisions based on evidence while keeping the patient (and family members, as necessary) at the center of care. A decision made in collaboration with the patient takes into account their values and preferences, along with the best available research findings, the clinician’s knowledge, experience, and competence, thus fulfilling the philosophical underpinnings of evidence-based practice.

Open communication between the patient and the clinician is shared decision-making. The clinician uses his/her communication skills to actively listen, engage, and elicit patient preferences (a process called cognitive debriefing), advise the patient to take their preferences into consideration and address the patient’s concerns. In the process, the clinician provides evidence-based information about the options and balanced information about the benefits, ill effects, and uncertainties of each option (including watchful waiting where appropriate). The patient is made aware of their health and how it can impact their day-to-day activities while addressing their expectations and worries, values, and preferences for the available options, which may be influenced by their past experiences, those of their friends, or external factors (such as cost and treatment burden).

Why is it crucial to use collaborative decision making? The perspectives of both clinicians and patients are crucial; once merged, they can improve both patient and physician satisfaction regarding care. Ineffective communication or insufficient information to make an informed decision are the main causes of patient health care complaints. When a health care decision must be made, shared decision-making is the means to promote effective patient-physician communication and provides patients an opportunity to make an educated choice. The unequal power relations present in the classic hierarchical approach can be reduced by ensuring both clinician and patient have pertinent and useful information to contribute to the decision-making process. Patients should be given the opportunity and freedom to engage as much or as little as they would like in the decision-making process regarding their health care since shared decision-making is an ethical need. The expectations and assumptions many people have about interventions, about how much and how they can help can be managed with the support of shared decision-making. Patients and doctors typically exaggerate the advantages of interventions and understate their drawbacks. In addition, a lot of physiotherapists and patients base their opinions on “mechanistic thinking” (i.e., how the intervention should function), rather than empirical reasoning (i.e., does the intervention work?). For instance, despite electro modalities not having evidence for low back pain, many patients request these interventions based on the idea that “something has to be done” externally for the problem to feel better. Patients involved in shared decision-making can appreciate that outcome is more important than the application of an external modality. Patient’s expectations of the advantages and disadvantages of their alternatives are made more clear with the use of shared decision-making. As a result, low-value care can be minimized (minimizing overtreatment), while increasing the adoption of high-value care. Moreover, patients who opt to participate in the decision-making process report feeling better informed, contented, and capable of knowing what matters most to them while making treatment decisions. This results in less decisional conflict compared to those not knowing which option best matches their beliefs and preferences or not having realistic estimates of their chance of success. Shared decision-making research, on the other hand, is a relatively new and expanding area of study. Clinical outcomes after collaborative decision-making have not yet been evaluated in any trial. No study that was included in a comprehensive evaluation of research using shared decision-making in patients with musculoskeletal pain examined patient-reported health outcomes.

When is it permissible to use collaborative decision making? Although collaborative decision-making has been called the “Brahmastra” of physiotherapy, it is crucial to understand when it is and when it is not suitable. For instance, it is often less suitable and unnecessary when a single, unquestionably superior therapeutic choice is available (for example, a person with non-specific low back pain should be encouraged to remain active, rather than bed rest). It is most appropriate when multiple options are available, each with comparable effectiveness but a different benefit-harm profile (costs, benefit type, harm type, etc.), thereby requiring “value judgment.” The bulk of intervention decisions in physiotherapy are what are known as preference sensitive decisions.

Including shared decision-making in the care of chronic illnesses that necessitate creating action plans and establishing goals, as well as in patients with multimorbidities is also acceptable. Shared decision-making is appropriate for use in all settings, including emergency, outpatient, and inpatient departments, community health, private practice, educational settings, and workplaces. It is also applicable to many types of health care decisions, including screening, testing, prevention, and treatment, and is known as a preference sensitive decision, which constitutes a majority of intervention decisions in physiotherapy. Important components of the joint decision-making process, though it is frequently not a linear process as depicted in Figure 1, the pieces may be revisited during the interaction. The components of the shared decision-making process illustrated in Figure 1 are all important. Hoffmann and colleagues’ publication for examples of specific physiotherapy clinical cases is an excellent resource. The fact that there may be insufficient data for some conclusions regarding the advantages and disadvantages of one or more of the available options is one of the obstacles of shared decision-making. This problem might arise when using evidence-based practice as well as collaborative decision-making. While there are many gaps in the evidence base for the always expanding physiotherapy profession, judgments should be made based on the best evidence that is currently available, and this uncertainty should be shared with patients.

In conclusion, shared decision-making is a crucial aspect in improving patient satisfaction, but further research is needed in the field of physiotherapy. In India, patients’ beliefs and knowledge are a concern, especially in the age of the internet and “WhatsApp” doctors. But the area is something that needs to be considered seriously.

 Conflict of interest

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