Shared decision-making in medicine
Shared decision-making in medicine (SDM) is a process in which both the patient and physician contribute to the medical decision-making process. Health care providers explain treatments and alternatives to patients and help them choose the treatment option that best aligns with their preferences as well as their unique cultural and personal beliefs.
In contrast to SDM, the traditional biomedical care system placed physicians in a position of authority with patients playing a passive role in care. Physicians instructed patients about what to do, and patients rarely took part in the treatment decision.
- 1 History
- 2 Patient autonomy and informed consent
- 3 Models
- 4 Decision aids
- 5 Implementation
- 6 Measurement
- 7 Expansion
- 8 Patient empowerment
- 9 Benefits
- 10 Problems
- 11 Conferences
- 12 See also
- 13 References
- 14 External links
One of the first instances where the term shared decision-making was employed was in a report on ethics in medicine by Robert Veatch in 1972.[non-primary source needed] It was used again in 1982 in the "President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research." This work built on the increasing interest in patient-centredness and an increasing emphasis on recognising patient autonomy in health care interactions since the 1970s.[non-primary source needed] Some would even claim that a general paradigm shift occurred in the 1980s in which patients became more involved in medical decision-making than before.[non-primary source needed] For example, a 2007 review of 115 patient participation studies found that the majority of respondents preferred to participate in medical decision-making in only 50% of studies prior to 2000, while 71% of studies after 2000 found a majority of respondents who wanted to participate.
Charles et al. described a set of characteristics of shared decision-making, stating “that at least two participants, the clinician and patient be involved; that both parties share information; that both parties take steps to build a consensus about the preferred treatment; and that an agreement is reached on the treatment to implement". This final element is not fully accepted by everyone in the field. The view that it is acceptable to agree to disagree is also regarded as an acceptable outcome of shared decision-making.[non-primary source needed]
Patient autonomy and informed consent
The basic premise of SDM are both patient autonomy and informed consent. The model recognizes that patients have personal values that influence the interpretation of risks and benefits differently from the way a physician interprets them. Informed consent is at the core of shared decision-making,  i.e. without fully understanding the advantages and disadvantages of all treatment options, patients cannot engage in making decisions. But there is frequently more than one option, with no clear choice of which option is best, especially when the decision at hand is about a preference-sensitive condition. Shared decision-making differs from informed consent in that patients base their decisions on their values and beliefs, as well as on being fully informed. Thus in certain situations the physician's point of view may differ from the decision that aligns most with the patient's values, judgments, and opinions. Also, a physician may be motivated by financial incentives such as fee-for-service.
Factors that predict participation
There are certain patient characteristics that influence the extent of involvement. Research shows that female patients who are younger and more educated and have a less severe illness than other patients are more likely to participate in medical decisions. That is, an increase in age leads to a decrease in desire to participate, while higher levels of education increase participation levels. However, other research has offered conflicting evidence for the effect of age on level of participation. One study found that age did not inversely relate to participation levels. In addition, numeracy levels may play an important role in SDM. Recent research has shown that, in general, low-numeracy individuals in both Germany and the United States prefer to play a more passive role than their high-numeracy counterparts. That is, individuals who are not as fluent with numbers and statistics tended to let their physicians make medical decisions without much input from the patients. In general, however, Americans play a more active role in the physician-patient relationship, by performing activities like asking follow-up questions and researching treatment options, than do Germans. Furthermore, research shows that race plays an important role in whether a patient participates. Though black patients report that they participate less in shared decision-making than white patients, studies have shown that black patients desire to participate just as much as their white counterparts and are more likely to report initiating conversation about their health care with their physicians.
Individuals who place a higher value on their health are more likely to play a passive role when it comes to medical decision-making than those who placed a lower value on health. Researchers Arora and McHorney posit that finding may be the result of their apprehension when it comes to health-related concerns among those who place a high value on health, leading to a tendency to let an expert, rather than themselves, make important medical decisions.
There is some evidence that giving patients real-time, unfettered access to their own medical records increases their understanding of their health and improves their ability to take care of themselves.
Elwyn et al. described a set of competences for shared decision-making, which are composed of the steps of defining the problem which requires a decision, the portrayal of equipoise and the uncertainty about the best course of action, thereby leading to the requirement to provide information about the attributes of available options and support a deliberation process. An assessment scale to measure the extent to which clinicians involve patients in decision-making has been developed and translated into Dutch, Chinese, French, German, Spanish and Italian. A talk model has been recently proposed, composed of three different phases: team, option and decision talk. In the first of these phases, clinicians' work to create a supportive relationship with the patient as they introduce the idea of recognizing the existence of alternative actions (options) - this is to form a team with the patient and their family. In the second phase, the work is to introduce the options in a clear way, describing and explaining the probabilities of benefits and harms that might be likely - this is option talk. In the last phase, patients' preferences are constructed, elicited and integrated - this is decision talk. A shorter 5-item version of the Observer OPTION measure has been published based on this model. 
The ecological model of SDM, proposed by Cegala and based on previous research by Street, includes four main components of SDM. The first is termed information seeking. Assessment for this component includes the number of health-related questions the patient asks along with the number of times the patient asks for the physician to verify information. Examples of information verifying may include asking a physician to repeat information or summarizing what the physician said in order to ensure that the patient understood the information. The second facet of SDM, as proposed by this model, is assertive utterances, which may include making recommendations to physicians, expressing an opinion or preference, or expressing disagreement. The third component of the model is information provision of symptoms, medical history and psychosocial factors, with or without prompting from the physician. The final component of SDM is expressions of concern, including affective responses such as anxiety, worry, or negative feelings. The extent of participation can be determined based on how often a patient displays these four overarching behaviors.
SDM increasingly relies on the use of decision aids in assisting the patients in choosing the best treatment option. Patient decision aids, which may include leaflets, video or audio tapes, or interactive media, supplement the patient-physician relationship and assist patients in making medical decisions that most closely aligns with their values and preferences. Recently, interactive software or internet websites have helped bridge the divide between physician and patients. Research has shown that the use of decision aids may increase patients' trust in physicians, thereby facilitating the shared decision-making process. Many research and implementation studies conducted up to 2010 are contained in the book Shared Decision Making in Healthcare: Evidence-based Patient Choice, 2nd ed.[page needed]
The International Patient Decision Aid Standards (IPDAS) Collaboration, a group of researchers led by professors Annette O'Connor in Canada and Glyn Elwyn in England, has published a set of standards, representing the efforts of more than 100 participants from 14 countries around the world to will help determine the quality of patient decision aids. The report determined that there are certain components of an aid, such as providing information about options, using patient stories, and disclosing conflicts of interest, that will assist patients and health practitioners to assess the content, development process, and effectiveness of decision aids.
With funding bodies emphasizing knowledge translation, i.e. making sure that scientific research results in changes in practice, researchers in shared decision-making have focussed on implementing SDM, or making it happen. Based on studies of barriers to shared decision-making as perceived by health professionals  and patients, many researchers are developing sound, theory-based training programs and decision aids, and evaluating their results. Canada has established a research chair that focusses on practical methods for promoting and implementing shared decision-making across the healthcare continuum.
Although patients who are involved in decision-making about their health have better outcomes, healthcare professionals rarely involve them in these decisions. A recently updated Cochrane review  has synthesized the body of evidence about different interventions that can be used to help healthcare professionals adopt practices to better involve their patients in the process of making decisions about their health. In this review of studies testing interventions to help healthcare professionals adopt practices to better involve their patients in the process of making decisions, five studies were identified. This review found that educational meetings, giving healthcare professionals feedback, giving healthcare professionals learning materials, and using patient decision aids are some techniques that have been tried and might be helpful. However, the review could not determine from the available studies which of these were best. The review makes some suggestions for how research studies could better evaluate healthcare professionals involving patients in the process of making decisions about their health so that we can understand this better in the future. There is also a need for greater conceptual clarity. Involving patients in decisions is by definition a process that could occur over time and in many encounters. Much of the literature seems to assume that achieving shared decision-making is a matter of giving healthcare professionals enough information.
Canada, Germany and the U.S.
Training health professionals in shared decision-making attracts the attention of policy makers when it shows potential for addressing chronic problems in healthcare systems such as the overuse of drugs or screening tests. One such program, designed for primary care physicians in Quebec, Canada, showed that shared decision-making can reduce use of antibiotics for acute respiratory problems (ear aches, sinusitis, bronchitis, etc.) which are often caused by viruses and do not respond to antibiotics.
While some medical schools (e.g. in Germany, the UK and Canada) already include such training programs in their residency programs, there is increasing demand for shared decision-making training programs by medical schools and providers of continuing professional education (such as medical licensing bodies). A 2012 inventory of existing programs (regularly updated) showed that they vary widely in what they deliver and are rarely evaluated. These observations led to an international effort to list the skills necessary for practising shared decision-making and to prioritize them. The effort generated debate among researchers around what core competencies should be taught and how they should be measured, which brought the discussion back to basic questions: what exactly is shared decision-making, do decisions always have to be shared, and how can it be accurately evaluated?
Harvey Fineberg, Head of the US Institute of Medicine, has suggested that shared decision-making should be shaped by the particular needs and preferences of the patient, which may be to call on a physician to assume full responsibility for decisions or, at the other extreme, to be supported and guided by the physician to make completely autonomous decisions. This suggests that, just as with interventions, which need to match the patient's style and preferences, patient's preferences for degree of involvement also need to be taken into account and respected.
The aim of the Right Care Shared Decision-Making Programme is to embed shared decision-making in NHS care. This is part of the wider ambition to promote patient centred care, to increase patient choice, autonomy and involvement in clinical decision-making and make “no decision about me, without me” a reality. The Shared Decision-Making programme is part of the Quality Improvement Productivity and Prevention (QIPP) Right Care programme. In 2012, the programme entered an exciting new phase and, through three workstreams, is aiming to embed the practice of shared decision-making among patients and those who support them, and among health professionals and their educators. One of the components of the National Programme is the work of the Advancing Quality Alliance (AQuA) -  who are tasked with creating a receptive culture for shared decision-making with patients and health professionals.
Several researchers in this field have designed scales for measuring to what extent shared decision-making takes place in the clinical encounter and its effects, from the perspective of patients or healthcare professionals or both, or from the perspective of outside observers. The purpose of these scales is to explore what happens in shared decision-making and how much it happens, with the goal of applying this knowledge to incite healthcare professionals to practise it. Based on these scales, simple tools are being designed to help physicians better understand their patients’ decision needs. One such tool that has been validated, SURE, is a quick questionnaire for finding out in busy clinics which patients are not comfortable about the treatment decision (decisional conflict). SURE is based on O’Connor’s Decisional Conflict Scale  which is commonly used to evaluate patient decision aids. The four yes-or-no questions are about being Sure, Understanding the information, the Risk-benefit ratio, and sources of advice and Encouragement.
Another proposed measure explores the following three components of patient-centered behavior: physician's general ability to conceptualize both illness and disease in relation to a patient's life; physicians exploring the full context of illness in the patient's life setting (like work, social supports, family) and personal development; physicians' ability to reach common ground with the participants in which the treatment goals and management strategies, nature of the problems and priorities, and roles of both the physician and patient are addressed.
Earlier research demonstrated that increased patient-centered behavior by physicians led to greater compliance of patients' at-home medical care, such as taking pills. Generally, physicians engage in more patient-centered communication when they speaking with high participation patients rather than with low participation patients. However, when a patient sees a physician of the same race, the patient perceives that physician as involving the patient more than a physician of a different race.
Researchers in shared decision-making are increasingly taking account of the fact that involvement in making healthcare decisions is not always limited to one patient and one healthcare professional in a clinical setting. Often more than one healthcare professional is involved in a decision, such as professional teams involved in caring for an elderly person who may have several health problems at once. Some researchers, for example, are focussing on how interprofessional teams might practise shared decision-making among themselves and with their patients. Researchers are also expanding the definition of shared decision-making to include an ill person’s spouse, family caregivers or friends, especially if they are responsible for giving the person medicine, transporting them or paying the bills. Decisions that ignore them may not be based on realistic options or may not be followed through. Shared decision-making is also now being applied in areas of healthcare that have wider social implications, such as decisions faced by the frail elderly and their caregivers about staying at home or moving into care facilities.
Patient empowerment enables patients to take an active role in the decisions made about their own healthcare. Patient empowerment requires patients to take responsibility for aspects of care such as respectful communications with their doctors and other providers, patient safety, evidence gathering, smart consumerism, shared decision-making, and more.
The EMPAThiE study defined an empowered patient as a patient who "… has control over the management of their condition in daily life. They take action to improve the quality of their life and have the necessary knowledge, skills, attitudes and self-awareness to adjust their behavior and to work in partnership with others where necessary, to achieve optimal well-being."
Various countries have passed laws and run multiple campaigns to raise awareness of these matters. For example, a law enacted in France on 2 March 2002 aimed for a "health democracy" in which patients' rights and responsibilities were revisited, and it gave patients an opportunity to take control of their health. Similar laws have been passed in countries such as Croatia, Hungary, and the Catalonia. The same year, Britain passed a penalty charge to remind patients of their responsibility in healthcare.
In 2009, British and Australian campaigns were launched to highlight the costs of unhealthy lifestyles and the need for a culture of responsibility. The European Union took this issue seriously and since 2005, has regularly reviewed the question of patients' rights by various policies with the cooperation of the World Health Organization. Various medical associations have also followed the path of patients' empowerment by bills of rights or declarations.
A recent study found that individuals who participate in shared decision-making are more likely to feel secure and may feel a stronger sense of commitment to recover. Also, research has shown that SDM leads to higher judgments of the quality of care. Furthermore, SDM leads to greater self-efficacy in patients, which in turn, leads to better health outcomes. When a patient participates more in the decision-making process, the frequency of self-management behaviors increases, as well. Self-management behaviors fall into three broad categories: health behaviors (like exercise); consumeristic behaviors (like reading the risks about a new treatment); and disease-specific management strategies. In a similar vein, a recent study found that among patients with diabetes, the more an individual remembers information given by a physician, the more the patient participated in self-care behaviors at home.
Providing patients with personal coronary risk information may assist patients in improving cholesterol levels. Such findings are most likely attributed to an improvement in self-management techniques in response to the personalized feedback from physicians. Additionally, the findings of another study indicate that the use of a cardiovascular risk calculator led to increased patient participation and satisfaction with the treatment decision process and outcome and reduced decisional regret.
Some patients do not find the SDM model to be the best approach to care. A qualitative study found that barriers to SDM may include a patient's desire to avoid participation from lack of perceived control over the situation, a medical professional's inability to make an emotional connection with the patient, an interaction with an overconfident and overly-assertive medical professional, and general structural deficits in care that may undermine opportunities for a patient to exert control over the situation. Furthermore, dispositional factors may play an important role in the extent to which a patient feels comfortable with a participating in medical decisions. Individuals who exhibit high trait anxiety, for example, prefer not to participate in medical decision-making.
For those who do participate in decision-making, there are potential disadvantages. As patients take part in the decision process, physicians may communicate uncertain or unknown evidence about the risks and benefits of a decision. The communication of scientific uncertainty may lead to decision dissatisfaction. Critics of the SDM model assert that physicians who choose not to question and challenge the assumptions of patients do a medical disservice to patients, who are overall less knowledgeable and skilled than the physician. Physicians who encourage patient participation can help the patient make a decision that is aligned with the patients' values and preferences.
Many researchers and practitioners in this field meet every two years at the International Shared Decision Making (ISDM) Conference, which have been held at Oxford in 2001, Swansea in 2003, Ottawa in 2005, Freiburg in 2007, Boston in 2009, Maastricht in 2011, Lima in 2013, Sydney, (Aus) in 2015,  and Lyon in 2017. It will be held in Quebec City in 2019.
On December 12–17, 2010 the Salzburg Global Seminar began a series with a session focused on "The Greatest Untapped Resource in Healthcare? Informing and Involving Patients in Decisions about Their Medical Care." Powerful conclusions emerged among the 58 participants from 18 countries: not only is it ethically right that patients should be involved more closely in decisions about their own medical care and the risks involved, it is practical – through careful presentation of information and the use of decision aids/pathways – and it brings down costs. Unwarranted practice variations – where one area may have many more interventions than another, but with no better outcomes – are reduced, sometimes dramatically.
The Agency for Healthcare Research and Quality (AHRQ) Eisenberg Conference Series brings together “[e]xperts in health communication, health literacy, shared decision-making, and related fields come together to … offer insight into how state-of-the-art advances in medical science can be transformed into state-of-the-art clinical decision making and improved health communication.”
- Légaré, F; Witteman, H.O. (2013). "hared decision making: examining key elements and barriers to adoption into routine clinical practice". Health Aff (Millwood) (32): 276–84.
- Florin, Jan; Ehrenberg, Anna; Ehnfors, Margareta (November 2008). "Clinical decision-making: Predictors of patient participation in nursing care". Journal of Clinical Nursing. 17 (21): 2935–44. doi:10.1111/j.1365-2702.2008.02328.x. PMID 19034992. (Subscription required (help)).
- Lyttle, Diane J.; Ryan, Assumpta (December 2010). "Factors' influencing older patients' participation in care: A review of the literature". International Journal of Older People Nursing. 5 (4): 274–82. doi:10.1111/j.1748-3743.2010.00245.x. PMID 21083806. (Subscription required (help)).
- Buchanan, Allen (Summer 1978). "Medical paternalism". Philosophy & Public Affairs. 7 (4): 370–90. JSTOR 2264963. PMID 11664929. (Subscription required (help)).
- Veatch, R. 1972. Models for Ethical Medicine in a Revolutionary Age. The Hastings Center Report, 2, 5-7.
- Brock DW. The ideal of shared decision making between physicians and patients. Kennedy Institute of Ethics Journal. 1991;1(1):28-47.
- President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, 1982. Making Health Care Decisions. The Ethical and Legal Implications of Informed Consent in the Patient-Practitioner Relationship. Washington, 1982. Page 33.
- Engel, GL (May 1980). "The clinical application of the biopsychosocial model". Am J Psychiatry. 137 (5): 535–44. doi:10.1176/ajp.137.5.535. PMID 7369396. (subscription required)
- Levenstein JH (September 1984). "The patient-centred general practice consultation". South African Family Practice. 5 (9): 276–82.
- Barry MJ, Edgman-Levitan S. Shared decision making—the pinnacle of patient-centered care. New England Journal of Medicine. 2012 Mar 1;366(9):780-1.
- Epstein, Ronald M.; Campbell, Thomas L.; Cohen-Cole, Steven A.; McWhinney, Ian R.; Smilkstein, Gabriel (October 1993). "Perspectives on patient-doctor communication". Journal of Family Practice. 37 (4): 377–88. PMID 8409892.
- Higgs, J., Patton, N., Hummell, J., Tasker, D., Croker, A., & SpringerLink (Online service). (2014). Health Practice Relationships. (Springer eBooks.) Rotterdam: SensePublishers.p.38-41
- Chewning, Betty; Bylund, Carma L.; Shah, Bupendra; Arora, Neeraj K.; Gueguen, Jennifer A.; Makoul, Gregory (January 2012). "Patient preferences for shared decisions: A systematic review". Patient Education and Counseling. 86 (1): 9–18. doi:10.1016/j.pec.2011.02.004. PMC 4530615. PMID 21474265.
- Charles C, Gafni A, Whelan T (March 1997). "Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango)". Soc Sci Med. 44 (5): 681–92. doi:10.1016/S0277-9536(96)00221-3. PMID 9032835.
- Makoul G, Clayman ML (March 2006). "An integrative model of shared decision making in medical encounters". Patient Educ Couns. 60 (3): 301–12. doi:10.1016/j.pec.2005.06.010. PMID 16051459.
- Elwyn G, Edwards A, Kinnersley P (June 1999). "Shared decision-making in primary care: the neglected second half of the consultation". Br J Gen Pract. 49 (443): 477–82. PMC 1313449. PMID 10562751.
- Walker, Paul, and Terry Lovat. "Dialogic consensus in clinical decision-making." Journal of bioethical inquiry 13.4 (2016): 571-580.
- Whitney SN, McGuire AL, McCullough LB (January 2004). "A typology of shared decision making, informed consent, and simple consent". Ann. Intern. Med. 140 (1): 54–9. doi:10.7326/0003-4819-140-1-200401060-00012. PMID 14706973.
- Mulley AG, Eagle KA (1988). "What is inappropriate care?". JAMA. 260 (4): 540–1. doi:10.1001/jama.1988.03410040112039. PMID 3290528.
- Arora NK, McHorney CA (March 2000). "Patient preferences for medical decision making: who really wants to participate?". Med Care. 38 (3): 335–41. doi:10.1097/00005650-200003000-00010. PMID 10718358.
- Galesic M, Garcia-Retamero R (May 2011). "Do low-numeracy people avoid shared decision making?". Health Psychol. 30 (3): 336–41. doi:10.1037/a0022723. PMID 21553977.
- Cooper-Patrick L, Gallo JJ, Gonzales JJ, Vu HT, Powe NR, Nelson C, Ford DE (August 1999). "Race, gender, and partnership in the patient-physician relationship". JAMA. 282 (6): 583–9. doi:10.1001/jama.282.6.583. PMID 10450723.
- Peek ME, Tang H, Cargill A, Chin MH (2011). "Are there racial differences in patients' shared decision-making preferences and behaviors among patients with diabetes?". Med Decis Making. 31 (3): 422–31. doi:10.1177/0272989X10384739. PMC 3482118. PMID 21127318.
- "Engaging Patients Through OpenNotes: An Evaluation Using Mixed Methods". Commonwealth Fund. 16 February 2016. Retrieved 17 February 2016.
- Elwyn G, Edwards A, Kinnersley P, Grol R (November 2000). "Shared decision making and the concept of equipoise: the competences of involving patients in healthcare choices". Br J Gen Pract. 50 (460): 892–9. PMC 1313854. PMID 11141876.
- Elwyn G, Hutchings H, Edwards A, Rapport F, Wensing M, Cheung WY, Grol R (March 2005). "The OPTION scale: measuring the extent that clinicians involve patients in decision-making tasks". Health Expect. 8 (1): 34–42. doi:10.1111/j.1369-7625.2004.00311.x. PMC 5060272. PMID 15713169.
- "OPTION Instrument Sheet Translations". OPTION: Observing patient involvement in shared decision making. Decision Laboratory, Department of Primary Care & Public Health, Cardiff University. Archived from the original on 9 October 2011.
- Elwyn G, Tsulukidze M, Edwards A, Légaré F, Newcombe R (November 2013). "Using a 'talk' model of shared decision making to propose an observation-based measure: Observer OPTION 5 Item". Patient Education and Counseling. 93 (2): 265–71. doi:10.1016/j.pec.2013.08.005. PMID 24029581.
- Street, Richard L. (2003). "Communication in medical encounters: An ecological perspective". In Thompson, Teresa L.; Dorsey, Alicia; Parrott, Roxanne; Miller, Katherine. The Routledge Handbook of Health Communication. Routledge Communication Series. Routledge. pp. 63–89. ISBN 978-1-135-64766-7 – via Google Books.
- Cegala, Donald J. (July 2011). "An exploration of factors promoting patient participation in primary care medical interviews". Health Communication. 26 (5): 427–36. doi:10.1080/10410236.2011.552482. PMID 21416422. (Subscription required (help)).
- van Til, J.A.; Drossaert, C. C.; Renzenbrink, G. J.; Snoek, G. J.; Dijkstra, E.; Stiggelbout, A. M.; IJzerman, M. J. (2010). "Feasibility of web-based decision aids in neurological patients". Journal of Telemedicine and Telecare. 16 (1): 48–52. doi:10.1258/jtt.2009.001012.
- Frosch DL, Bhatnagar V, Tally S, Hamori CJ, Kaplan RM (February 2008). "Internet patient decision support: a randomized controlled trial comparing alternative approaches for men considering prostate cancer screening". Arch. Intern. Med. 168 (4): 363–9. doi:10.1001/archinternmed.2007.111. PMID 18299490.
- Barry MJ (January 2002). "Health decision aids to facilitate shared decision making in office practice". Ann. Intern. Med. 136 (2): 127–35. doi:10.7326/0003-4819-136-2-200201150-00010. PMID 11790064.
- Kypri K, Langley JD, Saunders JB, Cashell-Smith ML, Herbison P (March 2008). "Randomized controlled trial of web-based alcohol screening and brief intervention in primary care". Arch. Intern. Med. 168 (5): 530–6. doi:10.1001/archinternmed.2007.109. PMID 18332300.
- Nannenga, Michael R.; Montori, Victor M.; Weymiller, Audrey J.; Smith, Steven A.; Christianson, Teresa J.H.; Bryant, Sandra C.; Gafni, Amiram; Charles, Cathy; Mullan, Rebecca J.; Jones, Lesley A.; Bolona, Enrique R.; Guyatt, Gordon H. (March 2009). "A treatment decision aid may increase patient trust in the diabetes specialist. The Statin Choice randomized trial". Health Expectations. 12 (1): 38–44. doi:10.1111/j.1369-7625.2008.00521.x. PMC 5060475. PMID 19250151.
- Elwyn, Glyn; Edwards, Adrian, eds. (29 June 2009). Shared decision-making in health care: Achieving evidence-based patient choice (2nd ed.). Oxford University Press. ISBN 978-0-19-954627-5. Archived from the original on 5 February 2010.
- Elwyn G, O'Connor A, Stacey D, Volk R, Edwards A, Coulter A, Thomson R, Barratt A, Barry M, Bernstein S, Butow P, Clarke A, Entwistle V, Feldman-Stewart D, Holmes-Rovner M, Llewellyn-Thomas H, Moumjid N, Mulley A, Ruland C, Sepucha K, Sykes A, Whelan T (August 2006). "Developing a quality criteria framework for patient decision aids: online international Delphi consensus process". BMJ. 333 (7565): 417. doi:10.1136/bmj.38926.629329.AE. PMC 1553508. PMID 16908462.
- Légaré, F; Ratté, S; Gravel, K; Graham, ID (December 2008). "Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals' perceptions". Patient Education and Counseling. 3 (73): 526–35. doi:10.1016/j.pec.2008.07.018.
- Joseph-Williams, N; Edwards, A; Elwyn, G (14 May 2014). "Power imbalance prevents shared decision making". BMJ. 348: g3178. doi:10.1136/bmj.g3178. PMID 25134115.
- Canada Research Chair in Shared Decision Making and Knowledge Translation http://www.decision.chaire.fmed.ulaval.ca
- Stacey, D; Bennett CL; Barry MJ; Col NF; Eden KB; Holmes-Rovner M; Llewellyn-Thomas H; Lyddiatt A; Légaré F; Thomson R (2011). "Decision aids for people facing health treatment or screening decisions". Cochrane Database of Systematic Reviews (10): CD001431. doi:10.1002/14651858.CD001431.pub3. PMID 21975733.
- Couët, N; Desroches, S; Robitaille, H; Vaillancourt, H; Leblanc, A; Turcotte, S; Elwyn, G; Légaré, F (March 2013). "Assessments of the extent to which health-care providers involve patients in decision making: a systematic review of studies using the OPTION instrument". Health Expectations. 18: 542–61. doi:10.1111/hex.12054. PMC 5060794. PMID 23451939.
- Légaré, F; Adekpedjou, R; Stacey, D; Turcotte, S; Kryworuchko, J; Graham, ID; Lyddiatt, A; Politi, MC; Thompson, R; Elwyn, G; Donner-Banzhoff, N (2018). "Interventions for improving the adoption of shared decision making by healthcare professionals". Cochrane Database of Systematic Reviews: CD006732. doi:10.1002/14651858.CD006732.pub4. PMID 30025154.
- Légaré F, Labrecque M, Cauchon M, Castel J, Turcotte S, Grimshaw J (September 2012). "Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial". CMAJ. 184 (13): E726–34. doi:10.1503/cmaj.120568. PMC 3447039. PMID 22847969.
- Légaré, France. "Inventory of Shared Decision Making Programs for Healthcare Professionals". Canada Research Chair in Implementation of Shared Decision Making in Primary Care. Université Laval. Retrieved 12 February 2015.
- Légaré F, Politi MC, Drolet R, Desroches S, Stacey D, Bekker H (August 2012). "Training health professionals in shared decision-making: an international environmental scan". Patient Education and Counseling. 88 (2): 159–69. doi:10.1016/j.pec.2012.01.002. PMID 22305195.
- Légaré, F; Moumjid-Ferdjaoui, N; Drolet, R; Stacey, D; Härter, M; Bastian, H; Beaulieu, MD; Borduas, F; Charles, C; Coulter, A; Desroches, S; Friedrich, G; Gafni, A; Graham, ID; Labrecque, M; LeBlanc, A; Légaré, J; Politi, M; Sargeant, J; Thomson, R (Fall 2013). "Core competencies for shared decision making training programs: insights from an international, interdisciplinary working group". The Journal of Continuing Education in the Health Professions. 33 (4): 267–73. doi:10.1002/chp.21197. PMC 3911960. PMID 24347105.
- Fineberg, H. V. (2012). "From shared decision making to patient-centered decision making". Israel Journal of Health Policy Research. 1 (1): 6–20. doi:10.1186/2045-4015-1-6. PMC 3424821. PMID 22913639.
- "NHS Shared Decision Making Programme". Retrieved 29 December 2012.
- "Shared Decision Making". Advancing Quality Alliance (NHS). Retrieved 31 January 2014.
- Elwyn, G; Rix, A; Holt, T; Jones, D (2012). "Why do clinicians not refer patients to online decision support tools? Interviews with front line clinics in the NHS". BMJ Open. 2 (6): e001530. doi:10.1136/bmjopen-2012-001530. PMC 3532981. PMID 23204075.
- Scholl, I; Koelewijn-van Loon, M; Sepucha, K; Elwyn, G; Légaré, F; Härter, M; Dirmaier, J (2011). "Measurement of shared decision making - a review of instruments". Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen. 105 (4): 313–24. doi:10.1016/j.zefq.2011.04.012. PMID 21620327.
- O'Connor, AM (1995). "Validation of a decisional conflict scale". Medical Decision Making. 15 (1): 25–30. doi:10.1177/0272989x9501500105. PMID 7898294.
- Stacey, D; Légaré, F; Col, NF; Bennett, CL; Barry, MJ; Eden, KB; Holmes-Rovner, M; Llewellyn-Thomas, H; Lyddiatt, A; Thomson, R; Trevena, L; Wu, JH (2014). "Decision aids for people facing health treatment or screening decisions". The Cochrane Database of Systematic Reviews. 1: CD001431. doi:10.1002/14651858.CD001431.pub4. PMID 24470076.
- Légaré, F; Kearing, S; Clay, K; Gagnon, S; D'Amours, D; Rousseau, M; O'Connor, A (2010). "Are you SURE?: Assessing patient decisional conflict with a 4-item screening test". Canadian Family Physician. 56 (8): e308–14. PMC 2920798. PMID 20705870.
- Ferron Parayre, A; Labrecque, M; Rousseau, M; Turcotte, S; Légaré, F (2014). "Validation of SURE, a four-item clinical checklist for detecting decisional conflict in patients". Medical Decision Making. 34 (1): 54–62. doi:10.1177/0272989x13491463. PMID 23776141.
- Meredith, Leslie; Stewart, Moira; Brown, Judith Belle (2001). "Patient-centered communication scoring method report on nine coded interviews". Health Communication. 13 (1): 19–31. doi:10.1207/S15327027HC1301_03. PMID 11370920. (Subscription required (help)).
- Stewart, Moira A. (1984). "What is a successful doctor–patient interview? A study of interactions and outcomes". Social Science & Medicine. 19 (2): 167–75. doi:10.1016/0277-9536(84)90284-3. PMID 6474233. (Subscription required (help)).
- Légaré, F; Stacey, D; Pouliot, S; Gauvin, FP; Desroches, S; Kryworuchko, J; Dunn, S; Elwyn, G; Frosch, D; Gagnon, MP; Harrison, MB; Pluye, P; Graham, ID (January 2011). "Interprofessionalism and shared decision-making in primary care: a stepwise approach towards a new model". Journal of Interprofessional Care. 25 (1): 18–25. doi:10.3109/13561820.2010.490502. PMC 3018136. PMID 20795835.
- Zhang AY, Siminoff LA (2003). "The role of the family in treatment decision making by patients with cancer". Oncology Nursing Forum. 30 (6): 1022–8. doi:10.1188/03.ONF.1022-1028. PMID 14603359.
- Légaré, F; Brière, N; Stacey, D (2015). "Improving Decision making On Location of Care with the frail Elderly and their caregivers (the DOLCE study): study protocol for a cluster randomized controlled trial". Trials. 16 (1): 50. doi:10.1186/s13063-015-0567-7.
- Torrey, Trisha (25 November 2014). "The Wise Patient's Guide to Being an Empowered Patient". Verywell. About, Inc.
- Suñol, Rosa; Somekh, David; Orrego, Carola; et al. (10 November 2014). EMPATHiE: Empowering patients in the management of chronic diseases (PDF) (Report). EU Health Programme; Consumers, Health, Agriculture and Food Executive Agency. p. 6.
- Laur, Audrey (September 2013). "Patients' responsibilities for their health". Medical Legal Journal. 81 (3): 119–123. doi:10.1177/0025817213497149. PMID 24057310. (subscription required)
- Höglund AT, Winblad U, Arnetz B, Arnetz JE (September 2010). "Patient participation during hospitalization for myocardial infarction: perceptions among patients and personnel". Scand J Caring Sci. 24 (3): 482–9. doi:10.1111/j.1471-6712.2009.00738.x. PMID 20230518.
- Weingart SN, Zhu J, Chiappetta L, Stuver SO, Schneider EC, Epstein AM, David-Kasdan JA, Annas CL, Fowler FJ, Weissman JS (June 2011). "Hospitalized patients' participation and its impact on quality of care and patient safety". Int J Qual Health Care. 23 (3): 269–77. doi:10.1093/intqhc/mzr002. PMC 3140261. PMID 21307118.
- Heisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA (April 2002). "The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management". J Gen Intern Med. 17 (4): 243–52. doi:10.1046/j.1525-1497.2002.10905.x. PMC 1495033. PMID 11972720.
- Hibbard JH, Mahoney ER, Stock R, Tusler M (August 2007). "Do increases in patient activation result in improved self-management behaviors?". Health Serv Res. 42 (4): 1443–63. doi:10.1111/j.1475-6773.2006.00669.x. PMC 1955271. PMID 17610432.
- Hibbard JH, Mahoney ER, Stockard J, Tusler M (December 2005). "Development and testing of a short form of the patient activation measure". Health Serv Res. 40 (6 Pt 1): 1918–30. doi:10.1111/j.1475-6773.2005.00438.x. PMC 1361231. PMID 16336556.
- Bundesmann R, Kaplowitz SA (November 2011). "Provider communication and patient participation in diabetes self-care". Patient Educ Couns. 85 (2): 143–7. doi:10.1016/j.pec.2010.09.025. PMID 21035296.
- Grover SA, Lowensteyn I, Joseph L, Kaouache M, Marchand S, Coupal L, Boudreau G (November 2007). "Patient knowledge of coronary risk profile improves the effectiveness of dyslipidemia therapy: the CHECK-UP study: a randomized controlled trial". Arch. Intern. Med. 167 (21): 2296–303. doi:10.1001/archinte.167.21.2296. PMID 18039987.
- Krones T, Keller H, Sönnichsen A, Sadowski EM, Baum E, Wegscheider K, Rochon J, Donner-Banzhoff N (2008). "Absolute cardiovascular disease risk and shared decision making in primary care: a randomized controlled trial". Ann Fam Med. 6 (3): 218–27. doi:10.1370/afm.854. PMC 2384995. PMID 18474884.
- Larsson, Inga E.; Sahlsten, Monika J.M.; Segesten, Kerstin; Plos, Kaety A.E. (September 2011). "Patients' perceptions of barriers for participation in nursing care". Scandinavian Journal of Caring Sciences. 25 (3): 575–82. doi:10.1111/j.1471-6712.2010.00866.x. PMID 21241347. (Subscription required (help)).
- Graugaard, Peter; Finset, Arnstein (January 2000). "Trait anxiety and reactions to patient-centered and doctor-centered styles of communication: An experimental study". Psychosomatic Medicine. 62 (1): 33–39. doi:10.1097/00006842-200001000-00005. PMID 10705909. (Subscription required (help)).
- Politi, Mary C.; Clark, Melissa A.; Ombao, Hernando; Dizon, Don; Elwyn, Glyn (March 2011). "Communicating uncertainty can lead to less decision satisfaction: a necessary cost of involving patients in shared decision making?". Health Expectations. 14 (1): 84–91. doi:10.1111/j.1369-7625.2010.00626.x. PMC 3010418. PMID 20860780.
- Cribb, Alan; Entwistle, Vikki A. (June 2011). "Shared decision making: trade-offs between narrower and broader conceptions". Health Expectations. 14 (2): 210–9. doi:10.1111/j.1369-7625.2011.00694.x. PMC 5060567. PMID 21592264.
- "ISDM/ISEHC2015: Bringing Evidence-Based Practice and Shared Decision-Making Together". International Society for Evidence Based Health Care (ISEHC) and International Shared Decision-Making (ISDM). Archived from the original on 29 October 2015.
- "Session 477". Salzburg Global Seminar. Salzburg Global Seminar. Retrieved 12 February 2016.
- Salzburg Global Seminar (22 March 2011). "Salzburg statement on shared decision making". BMJ. 342: d1745. doi:10.1136/bmj.d1745. PMID 21427038.
- "Eisenberg Center Conference Series". Agency for Healthcare Research and Quality. U.S. Department of Health & Human Services. Retrieved 19 September 2016.