CanMeds Communicator
Shared Decision-Making

Shared Decision-Making


What is Shared Decision-Making?

Shared decision-making is "finding common ground with patients about management"[3]

In the shared decision-making model of care, patients play an active role in choosing the treatment plan. This is a different mindset from the paternalistic tradition of doctors just telling the patient what to do. In order to involve the patient in the decision making process, one must connect with the patient in a meaningful way. For example, seeing the patient’s point of view and acknowledging and reiterating this point of view can be useful.

Critics of this model may point out that it is the physician’s duty to make treatment decisions, because the physician is the expert. Though the physician is an expert, the consequences of decisions will be felt by the patient, as it is her or his body that will be undergoing treatment!  Physicians, therefore, have a duty to engage their patients in the decision-making process. As well, patient participation in medical decision making may result in increased patient knowledge, satisfaction, adherence with treatment, and improved outcomes.[2]

A qualitative study[2] sheds light on the essential elements to enable patient participation. These are:

  1. Adequate patient knowledge of the situation

  2. Encouragement of participation of the patient

  3. Physician’s appreciation of the patient’s right to participate in decision-making.

  4. Awareness of the patient, that because uncertainty exists in medicine, there may be several choices for treatment

  5. Time

The time needed to educate the patient and listen to the patient’s viewpoint and concerns, is probably the biggest challenge for physicians.

An important distinction in SHARED decision making is that information transfer is TWO way.  This is in contrast to the "informed" decision making model, where information transfer is one way, with the doctor providing all the information the patient needs about the various treatment options to make a decision[1]. Here, deliberation is by the patient alone, or the patient in collaboration with friends or family.  This model does not give the opportunity for the physicians opinion or recommendation.  Thus, the patient does not benefit from the clinician’s expertise and experience.  A shared decision making approach honours both patient participation and physician expertise.



Photo by Yosemite 11:21, 14 Feb 2005 (UTC).Creative Commons License

Stuart and Liebarman [4] created the BATHE technique for rapid assessments of psychosocial factors affecting illness.  This method was meant to aid in decision making in a typical 15 minute interview. This mneumonic can be useful in other clinical encounters as it can help structure the interaction in order to ensure the patient’s participation.  This approach is also one of our favorites for the family medicine clinic environment where there can be a multitude of concerns.  A study in the United States showed that patients who were "BATHED" were more satisfied with their physician visit [5]









B- Background - helps elicit the context of the patient’s visit

" What is going on in  your life?"


A - Affect - allows the patient to report his/her current feeling state

"How do you feel about the?"

"What is your mood?"



T - Trouble - helps to focus on the issues of concern

"What about the situation troubles  you the most?"

"Is there anything about that that troubles you?"


H - Handling - evaluates psychological stress that may contribute to her/his illness

"How are you handling that?"

"How could you handle that?"


E - Empathy - expresses empathy or sympathy, conveys a sense of concern

"That must be very difficult for you."





List some of the barriers to incorporating shared decision making in your practice?


How do you intend to practice shared decision making in your future practice?


1. Murray E., Charles C., Gafni A. Shared decision-making in primary care: Tailoring the Charles et al. model to fit the context of general practice (2006) Patient Education and Counseling, 62 (2), pp. 205-211.

2. Liana Fraenkel and Sarah McGraw J Gen Intern Med. 2007 May; 22(5): 614–619. What are the Essential Elements to Enable Patient Participation in Medical Decision Making?

3. France Légaré, Stéphane Ratté, Karine Gravel, Ian D. Graham Patient Education and Counseling December 2008 (Vol. 73, Issue 3, Pages 526-535) Barriers and facilitators to implementing shared decision-making in clinical practice: Update of a systematic review of health professionals’ perceptions

4. Stuart MR, Lieberman JA. The fifteen minute hour: a short-term approach to psychotherapy in primary care, third edition. Philadelphia: Saunders, 2002.

5. Fam Med 2008;40(6):407-11

All references for this section