A new paper published in the Journal of Evaluation in Clinical Practice explores the nuances of the implementation and practice of shared decision-making in healthcare. Shared decision-making (SDM), at its best, empowers patients to make informed decisions about their own treatment. This can reduce the occurrence of clinical encounters where patients’ knowledge about their condition is devalued or dismissed by providers, an experience termed “epistemic injustice.”
The article, written by a group of Canadian practitioners and researchers, draws on the philosophical works of Hans-Georg Gadamer, Mikhail Bakhtin, Kenneth Burke, Miranda Fricker, and Paulo Freire. The authors argue that: “both the conceptualizations and enactment of shared decision-making are deeply shaped by one’s understanding of the term ‘shared.’
The article concludes with some practical suggestions for teachers and their role in promoting epistemic justice.
“Without major transformation in what, how, and with whom we teach, future clinicians may be unprepared to enact shared decision-making in a manner that does justice to the various ways of knowing.”
There are ongoing efforts to implement shared decision-making in psychiatry. The benefits of the practice in both mental health settings and broader health services are well-documented. SDM can open the door for tapering and deprescribing medication and encourages people to feel empowered to ask critical questions about their treatment plan.
Most importantly, shared decision-making is also thought to reduce the likelihood of epistemic injustice. Epistemic injustice, a phenomenon coined by philosopher Miranda Fricker, is understood as a harmful blow to one’s ability to understand their own experience. For example, if an epistemic authority, like a doctor, does not give their patient’s testimony credence, the patient may feel uncertain that their testimony was legitimate in the first place. SDM may reduce the likelihood of this phenomenon because SDM necessitates that both the practitioner and the patient are on an equal playing ground.
However, shared decision-making may not be implemented effectively when medical practitioners understand the word ‘shared’ differently. Drawing on philosophy, the authors argue that authentically ‘sharing’ requires the practitioner to go against what they have previously been taught about who has expertise in the clinical encounter. More specifically, to fully engage in shared decision-making requires practitioners to temporarily suspend their own claims on truth and become open to each patient’s knowledge.
Unfortunately, according to the authors, this way of working is incredibly challenging for the practitioner. They connect this difficulty to the way healthcare practitioners are taught. For shared decision-making to improve in practice, doctors must be trained differently.
The authors propose a pedagogical approach to healthcare and medical education that prioritizes early exposure to patient narratives and lived experiences, emphasizing epistemic justice.
They write that healthcare training should “make explicit why SDM is central to, rather than peripheral to, procedural forms of knowledge. They suggest that “academic programs include and recognize persons with patient experiences—who could also be students—as official members of the pedagogical team and include them in all levels of the educational continuum (from admissions to curriculum design, teaching, assessment, and program evaluation).”
Thomas, A., Kuper, A., Chin‐Yee, B., & Park, M. (2020). What is “shared” in shared decision-making? Philosophical perspectives, epistemic justice, and implications for health professions education. Journal of evaluation in clinical practice, 26(2), 409-418. (Link)