The process of shared decision-making (SDM) requires clinicians to set aside their personal biases or preferences for care, offer balanced information about all treatment options, and help patients’ navigate that information to arrive at their own decision. For learners striving to integrate reams of clinical knowledge and hone their clinical decision-making skills, the idea of sharing control over treatment recommendations may seem challenging. The role of educators is to model SDM in clinical encounters as well as didactic lectures. The objective is for learners to understand the role of SDM in patient-centered care as well as to implement SDM in cases where patients face choices amid equally effective and safe treatment options.
Last week we reported on a panel at the Forum advocating for a broader understanding of pregnancy desirability. This week, we are going to review a session called, “Prioritizing preferences in reproductive healthcare: the role of shared decision-making.” The presenters in this session examined three different moments of clinical decision-making when patient preference can and should be paramount.
First, Dr. Robin Wallace explored the need for SDM in early pregnancy loss (EPL) care. All EPL treatment options are equally safe and effective and patients have wide and diverse preferences for how their miscarriage is managed. Yet the treatments provided to patients experiencing EPL differentiate based on type of clinician. Research has shown that obstetricians/gynecologists utilize uterine aspiration in the operating room most often while family medicine physicians and nurse midwives primarily offer expectant management and refer out for uterine aspiration. [1, 2] All management options, including medication management and outpatient uterine aspiration, are within the scope of practice for a range of health care professionals. Shared decision-making reconciles the mismatch between patient preferences, evidence-based treatments, and current practice. Dr. Wallace suggests that all clinicians offering EPL care have an obligation to counsel about and provide all treatment options for patients with EPL and allow patient-preference to guide treatment decisions. Extensive clinical and training resources for patient-centered EPL management are available at no at earlypregnancylossresources.org.
Dr. Jennifer Kerns expanded Dr. Wallace’s premise into the realm of abortion after the first trimester for medical indications. Dr. Kerns rejects the notion that it is sufficient to ensure that a patient manages to access an abortion, regardless of what procedure is preferred. The options available for abortion at later gestations are deeply soiled in the US healthcare systems—medical induction terminations are mostly offered in hospital L&D units and surgical D&E procedures mostly in freestanding clinics. In addition to the preferences of clinicians for one procedure over the other, systems issues make it difficult for providers of one type of termination to facilitate referral into the other treatment stream. For this reason, many patients who have made an often heartbreaking choice to terminate their pregnancy because of medical indications are only offered one option, or hear counseling that is strongly biased. Clinicians often feel that the alternative procedure would be so difficult to access that offering counseling about the other option is presenting a false choice. Dr. Kerns argues that it is not for a clinician to decide what lengths a patient should go to access the care she prefers, but for the patient herself.
Finally, Dr. Christine Dehlendorf presented her case that contraceptive method choice is a clinical space appropriate for SDM. While effectiveness at pregnancy prevention does vary across contraceptive methods, Dr. Dehlendorf believes that effectiveness is just one of the many factors that go into a patient’s choice of method. As the panel on pregnancy intention made clear, avoiding pregnancy is not the only or most important motivation of many patients to use contraception. Many patients value the possibility of an unexpected pregnancy. Focusing on efficacy first, and patient preference specific factors second is not patient-centered care and may lead to lower satisfaction with the contraceptive method and lower trust in the health care provider.
All reproductive health decision-making takes place within the power dynamics and social structures of patients’ lives, including the history of reproductive coercion, forced sterilization, and bias between patients and providers. Using a shared decision-making model in reproductive health is a patient-centered step toward addressing that social context.