Patient-practitioner partnerships not yet realistic

(Medical Xpress) -- Much more work must be done to reduce the gap between the policy ideal and the practical reality of shared decision-making between patients and clinicians, according to new research from King’s College London.

Alan Cribb, Professor of Bioethics and Education at King’s, says that policy attempts to push the ‘involvement’ agenda will not succeed, and may even be counter-productive, unless the practical and ethical challenges and dilemmas surrounding the agenda of shared-decision making are explicitly addressed and fully reflected in policy initiatives and practice development.

He says the gap between policy ideals and routine practice can only be narrowed if both policy and practice are reformed.

In a discussion paper for the Royal Pharmaceutical Society, based on research funded by the AHRC, Professor Cribb calls for greater clarity on the range of different purposes and agendas being pursued in the area of medicines and patient involvement. He says ‘fudging’ these under single headings such as ‘shared decision-making’ or ‘choice’ is unhelpful and masks the diversity of approaches needed to tailor involvement to specific circumstances and cases and to address practice dilemmas.

Professor Cribb said: "The policy imperative in this area is justified but it won’t be addressed in practice unless the many challenges and ethical dilemmas associated with patient-professional partnerships are understood and honestly addressed.

"Despite a prevailing consensus within the healthcare sector that health professionals and patients should make decisions, including treatment choices, in partnership, there remains a substantial gap between the policy ideal and practice on the ground."

In his assessment, Professor Cribb looked at the reasons for such disparity, how the gap might be closed and at examples of successful practice. He says: "It is important to recognize that not all of the gap between ideals and practice should be seen as ‘resistance’ on the part of health professionals. We need to look again at the infrastructure and the tools that need to be put in place if we are to satisfactorily respond to calls for widespread partnership working."

Professor Cribb makes recommendations about how to address the challenges and how to formulate more realistic policy as an alternative to the ‘well meaning but simple policy solutions’ currently in place.

The paper identifies the infrastructural ‘stepping stones’ needed to ensure new models of working are feasible. These include:

Reforms in the area of professional leadership and education. Professor Cribb says these are fundamental because professionals need to be helped to move beyond narrow ‘competency’ based models – which tend to focus on communication skills – and to be supported in understanding and negotiating the dilemmas of partnership working and how this can be tailored to particular contexts and cases.

Senior representatives from a range of Royal Colleges have already met to discuss the paper and its implications for professional education.

Supporting and sharing practice development initiatives. It is vital that there is ‘bottom up’ as well as ‘top down’ change. There is, for example, a range of models, resources and processes available (e.g. information tools and medicines reviews) that services and professionals can adopt and adapt. However these are used much more effectively in some contexts than in others. The challenge is to identify, understand and spread various approaches to good practice and find ways of helping local services develop appropriate tools and tactics for the needs of their own patients. The examples presented and analysed in detail in the paper illustrate how this can be done.

Dr. Linda Patterson, Clinical Vice President of the Royal College of Physicians said: "Professor Alan Cribb makes a nuanced and considered argument for shared decision-making, which shares common themes with the Royal College of Physicians’ own work on improving communication and understanding between patients and clinicians. His analysis of the potential practical and ethical issues that need to be addressed to enable the successful implementation of shared decision-making will be of strong interest to medical professionals."