Of course, my first question to myself (which I raise only occasionally to others) is this: what are the assumptions here, and how is this going to help people feel better and live longer?
The assumptions are that people - most people? the average person? the person living the most engaged and healthiest life? - want to be involved in making health care decisions. Advocates of shared decision making like to point out that this is self-evidently true.
But, as I point out in my book, it's just not. Not because people are passive and would like doctors to walk all over them, but for any number of other reasons: they assume that doctors are in general skilled and have the patient's best interests at heart (sometimes true, sometimes - unfortunately - not); they are intimidated and made uncomfortable by the determinedly alien nature of our healthcare system; they are too stressed, poor, uneducated, or sick to keep their mind on anything so complicated as a healthcare decision. One solution to this just-not-so (or the "yeah-but" of the real world that gets in the way of many ideologies) is to explicitly encourage patients to take that step in sharing decision-making with their doctors, to become the passionate self-advocates that many assume we all should be.
But when that doesn't work, we should realize it's not patients' fault, or doctors: we need to remake our system. There are plenty of routes to do so. We can encourage doctors to involve patients in decisions by giving them money to do so; we can put more information in the hands of patients and explain it in a way they can understand; we can make it easier for poor patients, or those from disadvantaged groups, to access the care they need. Or - again, as I point out in my book - we can invest in the emotional foundation of care, a working patient-provider relationship that makes shared decision making more sustainable.
Does shared decision making lead to better health, less unequal care, and lower costs? It has that potential, at least for the first of those three. Whether shared decision making is the right star to chase, the direction to go in through the desert that will lead us to the triple aim of better care, lower costs, and greater satisfaction: that, I don't know. My personal preference is for communication and relationships to be our north star. I can believe in SDM, though, too!
[Picture from engagingthepatient.com]