In the mid-1980s, Canadian researcher David Sackett offered the first definition of evidence-based medicine, describing a Venn diagram where the best evidence overlaps with the clinician’s own experience and the patient’s values and expectations. Based on this definition, if we are truly committed to practicing evidence-based medicine, we must factor patient values and expectations into everything we do.

In order to deliver high-quality patient care at every encounter, clinicians must first understand what matters most to each patient. Only after engaging them appropriately can we then choose treatments that match their priorities and values, especially for patients with preference-sensitive conditions. Efforts can be guided by pursuing two foundational pillars of patient-centric care: participating in shared decision making and obtaining informed consent, better termed “informed choice.” Patients can exercise informed choice only when they are truly made aware of the risks, benefits and alternatives that exist relative to treatment.

Shared decision making is a process by which healthcare providers work collaboratively with their patients to make decisions about the most appropriate treatment. Shared decision making aligns with Sackett’s Venn diagram by using the following criteria:

  • Best available evidence
  • Clinical expertise
  • Patient values, preferences and circumstances

Shared decision making moves conversations from “What’s wrong with me?” to “What matters to me?” The Agency for Healthcare Research and Quality’s SHARE model and Elwyn’s three-talk model are two examples of shared decision making in action. Both emphasize understanding patients’ preferences, needs and values when weighing options, which requires open patient/clinician communication.

Informed consent is a legal and ethical requirement to ensure that patients fully understand their treatment options, including potential benefits, risks and alternatives. Effective informed consent adheres to the BRAN communication framework, answering these key questions:

  • Benefits — What are the potential positive outcomes?
  • Risks — What are the potential negative outcomes?
  • Alternatives — What other treatment options exist?
  • Nothing — What happens if no treatment is pursued?

Patients should receive this information clearly at every clinical encounter before agreeing to treatment. Importantly, according to the Joint Commission, only one in four consent forms contains all the BRAN elements. Ultimately, this framework transforms informed consent into informed choice, which is the goal of the process.

Research shows informed consent and shared decision making improve patient satisfaction and enhance treatment adherence and health outcomes while helping reduce the overall cost of care. When armed with full information and engaged in choices aligning treatments to their priorities, patients experience fewer regrets, better perceived communication and more active engagement in their care. Shared decision making also minimizes unwarranted variation in clinical practice. Relative to SDM and cost of care: Where options exist — such as in a patient with knee pain, which may be managed by participation in a walking group, physiotherapy, medical management or a surgical procedure — because patients are often more risk-averse than clinicians, they will often choose more conservative and less costly treatments before surgery, and thus, the total cost of care decreases.

However, research also suggests that clinicians rarely use best practices consistently. The use of “decision aids” and risk calculators during active patient consultation can help clinicians accurately convey hard-to-understand information to their patients. Using conversational techniques that meet patients where they are by accounting for health literacy and numeracy improves comprehension.

Communicating with the patient

How we share risk proportion is often driven by our own personal biases, so it’s important that when sharing an absolute number to represent risk, it’s vital to also share the inverse to most appropriately frame the idea of risk.

For example, if a treatment or therapy is associated with nausea and vomiting in one in five patients, it’s important to also share the associated inverse statistic: four in five patients will not develop this side effect.

Equally important, if you prefer using proportions, such as 20 percent of patients will experience nausea and vomiting following a given treatment, it’s important not only to state the inverse statistic that 80 percent of patients will not but also to convert both statistics to absolute numbers. (In this case, one in five patients will experience these side effects and four in five will not.)

Clinicians need to be educated on how to communicate not just the numbers, but the benefits, risks and alternatives in a compassionate and meaningful way.

Consider a case in which options are limited. In this case, the BRAN framework is vital, but one element is of monumental importance: Nothing. The physician must help the patient recognize that the only alternative to treatment is doing nothing and what doing nothing will produce, including a reduced quality of life or worse.

This situation raises another issue. To fully contextualize decisions for a given patient, the physician must understand the material and cultural conditions of that patient’s life: where they live, whether they have access to reliable transportation and housing, their level of literacy and numeracy, ethnic background and associated considerations or other related factors.

Our ability to understand these various elements in the context of the human being in front of us is critical to the BRAN conversation. This context is paramount in our ability to effectively obtain informed choice.

The short answer is no. As a general rule, we must meet patients where they are. Based on 2022 data, 79 percent of American adults are literate. However, one in two of them has a literacy level lower than sixth grade. As such, both what and how we communicate with our patients is vital.

It’s also important to recognize that informed consent isn’t a onetime deal; it’s an iterative process that happens throughout the continuum of care. Information should be parsed to the patient as their journey evolves, and informed choice should be made clear as choices change.

For one, healthcare leaders have an opportunity to better educate patients and the public that choice is a critical component of one’s own healthcare. Patients need to know they can and should drive the conversation.

Furthermore, ongoing education and implementation of easy-to-use tools that integrate informed consent across organizations elevate the perceived importance of shared decision making and drive wider adoption of patient-centered communication.

  • CollaboRATE is an easy-to-use, three-question, patient-reported measure of shared decision making, which is completed by the patient, family member or carer following each encounter. The tool was designed by Glyn Elwyn, MD, PhD, at the Dartmouth Institute for Health Policy and Clinical Practice.
  • Follow-up Assessment:
    • How much effort was made to help the patient understand their health issues?
    • How much effort was made to listen to things that matter most to the patient regarding their health issues?
    • How much effort was made by the clinician to include what mattered to the patient in choosing what to do?
  • Standardization of electronic informed consent and the elimination of paper-based checklists
    • Electronic health records systems allow departments to build rules that ensure regulatory compliance for e-consent.
    • Core protocols ensure consistent education and account for potential ignorance of evidence-based guidelines.

Remember that the delivery of high-quality healthcare encompasses not only clinical evidence and expertise but also understanding patient values and context. By implementing shared decision-making methods and pursuing informed consent throughout the care journey, we can give patients the agency they deserve while improving outcomes and reducing the cost of care. Prioritizing these practices will raise the bar on the level of care we can offer our communities, making healthcare work better for everyone.