Share
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Pons Ràfols, Montse Moharra Francés" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Joan M.V." "apellidos" => "Pons Ràfols" ] 1 => array:4 [ "nombre" => "Montse" "apellidos" => "Moharra Francés" "email" => array:1 [ 0 => "mmoharra@gencat.cat" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Agència de Qualitat i Avaluació Sanitàries de Catalunya, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Decisiones compartidas" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">No taxation without representation</span> (Slogan of the American colonists against the British authorities which would eventually end up in the revolution and independence of the USA).</p><p id="par0010" class="elsevierStylePara elsevierViewall">If the second half of the XVIII century was a period of radical economic and political changes, the decades following the II World War (XX century) was a period of profound medical and social changes. James Le Fanu explains the contradictions of the period, from the great medical successes that resulted from observation and experimentation to diminishing returns from research and intensified professional disenchantment.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> Healthcare managers assume physicians’ functions in the use of resources, so patients are increasingly complaining about a highly technological and even colder medicine. The costs of diagnosis and treatment of an increasingly scientific medicine have grown parallel to the popularity of so-called alternative and complementary medicines.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Therapeutic advances result from averaging the results of different experiments in many individuals. Assuming that they, not only reach statistical significance, but also clinical, one thing is for sure, they cannot ensure the effect (beneficial or adverse) on a particular person. Uncertainty can be mitigated, but cannot be completely eliminated. There is not just one truth, valid for everyone.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> If, to scientific and technological progress, we add the heterogeneity between individuals and the various treatment options with their pros and cons, which arise with the same clinical condition, the need for a weighted assessment is unquestionable, and this corresponds undoubtedly to the person who is most affected by the medical decisions: patients or healthy individuals (primary prevention interventions and screening).</p><p id="par0020" class="elsevierStylePara elsevierViewall">This, however, has not been the case until very recently. If anything has characterized the doctor–patient relationship has been the information asymmetry, at least until the technological revolution in information and communications. This imbalance in knowledge also favours the healthcare professional acting as an agent on behalf of the other: the patient.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> It is hoped that the principles of professionalism and ethics (duty and moral standards) will protect the patient from potential conflicts of interest when the objectives, that should be shared, diverge.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In public health systems that protect the entire population and are funded by taxes, both, professional and patient, must also remember that resources belong to everyone, that is, they have to take care of the collective or common interest, while this opposition (individual against society) continues being a permanent source of conflict.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> Professionalism is, however, the basis of the social contract of medicine and its fundamental principles are the primacy of patient welfare, the scrupulous respect for the patient's autonomy (to be honest with patients and facilitate their role as decision makers in areas that affect them) and social justice (in the distribution of resources and the elimination of all forms of discrimination).<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The models of professional relationship between doctor and patient (or healthy individual) have changed over time. The oldest, practiced by the priests of Asclepius and popular until very recently, was the paternalistic, authoritarian model, where the doctor was the dominant, intercessory and decision-making figure.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> No questions were asked. Economic, political and social changes, with the preeminence acquired by the principle of autonomy in today's consumer society, have cracked this monolithic authority.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Today, we talk about 3 coexisting models. The informative or technical model, where the professional provides a service to the customer or consumer, who knows (or thinks he/she knows) what he/she wants. There are no questions asked, but this time by the professional, who thinks everything is the other party's choice: the patient will have to face the consequences! (as long as the things demanded are feasible or risk-free). In this “consumer” model, the physician is a purveyor of technical expertise. The interpretive model supports the wishes of the patient. It aims to know the patient's preferences and make the best selection according to the values expressed. There is patient involvement, not so much professional input, although more than the information model.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> Finally, we have the deliberative model, which corresponds to the shared decision processes discussed below.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In shared decision making, professionals and patients work together to choose those tests or treatments that, on the basis of scientific evidence, better align with the patient's preferences and values.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> These decisions are particularly suitable in situations where there is more than one alternative before a diagnosis or screening, medical or surgical procedure, drug treatment or changes in lifestyle. They are especially useful when decisions are sensitive to patient preferences or when there is uncertainty about treatment effectiveness.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> Although these deliberative models can be more popular in clinical situations with several possible alternatives, we must not forget that there is always the option of doing nothing (outside palliate and accompany, according to the purpose of medicine), which, in some circumstances it may be the best option.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In addition, it involves the maximum involvement of the 2 parties, to the extent that it is said that the professional acts, rather than as an agent, as a teacher or friend.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> As in the other models, it assumes the provision of accurate and verified information about the options, the results (benefits and risks) in the real context and persistent uncertainties. An essential element is a sufficient level of health literacy<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> and numerical understanding (<span class="elsevierStyleItalic">Health numeracy</span>) which also involves language adaptation and easily intelligible data presentation formats (probability, statistics).<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">International experiences in shared decision making are diverse; for example, the tools developed in Canada, USA, or the United Kingdom. In our context, we need to add the one implemented by the Canary Islands<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> and Catalonia.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> The rise in these initiatives has led to the creation of an international group that has developed qualitative standards for decision support tools<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> in order to ensure quality and effectiveness. It includes aspects on content valuation (systematic, data understanding, simplicity in language), on the tool development process (review of content, updating information, disclosure of any conflict of interest) and on the effectiveness (balance between the options to consider which concern the most or that can help patients to know the different options).</p><p id="par0055" class="elsevierStylePara elsevierViewall">There is no doubt that these shared decision processes will become more frequent and extended over time. There is no way back. However, the change of mentality, applicable to both parties, will not happen overnight. We must all learn, starting with the professionals, with their communication skills, or patients, with assuming responsibility for their own body and health. Tools that facilitate this process must also be developed by all concerned parties (patients, professionals, scientific societies, patient and family associations).</p><p id="par0060" class="elsevierStylePara elsevierViewall">Being different factors that may act against its implementation, the main barrier is time, time for consultation and relationship, a scarce resource today due to overwork and the lack of knowledge in general of such tools.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a> However, decision support tools can save time and certainly should have other health professionals involved. They are also tools that can improve the quality of care and treatment compliance as the patient feels part of the decision.</p><p id="par0065" class="elsevierStylePara elsevierViewall">But if there is no will, conviction and involvement of the whole team, little can be done despite having all the time in the world. Shared decisions, which, to some degree, are already being implemented, represent a major cultural change for all participants in the health system, including health service funders and drug-medical device suppliers. Information, more than ever, must be accurate, not misleading; advertising is not what is needed.</p><p id="par0070" class="elsevierStylePara elsevierViewall">If one of the slogans that precipitated the American revolution and independence was the cry of “no taxation without representation”, in the field of health, the appropriate slogan would be: “<span class="elsevierStyleItalic">Nothing about me without me”</span>, which emerged from the campaigns to reduce the stigma of mental disorders, launched by the British <span class="elsevierStyleItalic">National Health Service</span> in 2011.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> In even simpler terms, one could mention the song by Al Hoffman and Dick Manning, <span class="elsevierStyleItalic">Takes two to tango</span> (1952), which also cited one of the first studies<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a> defining the basic elements involved in the shared decision making process: the doctor and the patient. Both share information, discuss about the best clinical treatment and eventually reach an agreement on the most appropriate choice.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pons Ràfols JMV, Moharra Francés M. Decisiones compartidas. Med Clin (Barc). 2016;146:205–206.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The rise and fall of modern medicine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. 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