Doug Opel, MD, MPH
It used to be that doctors told patients what to do, and often administered treatments without asking the patients for their opinion, despite there being several treatment options to consider. That paternalistic model has long been replaced in medicine
with an approach where the patient is viewed as a partner in the decision-making process. This middle ground is called shared decision-making (SDM). The shift to SDM has many benefits. For instance, it can result in better informed, empowered and satisfied patients. To realize these benefits, though, clinicians need to know how to implement SDM. Therein lies the rub: There is no single working definition for SDM in pediatrics and no consensus about when to use it.
Recognizing a Lack of a Standardized Approach
Treuman Katz Center faculty member Dr. Doug Opel finds that he experiences this confusion firsthand in his clinical work. As a general pediatrician, he talks frequently with parents about interventions that are recommended for their children in order to prevent disease. These interventions range from immunizations to anemia screening to vitamin K prophylaxis. For some of these interventions, Opel uses SDM by partnering with parents and inviting them to participate in the decision-making process. For instance, he might say, “How do you feel about a blood test today to make sure she doesn’t have low iron?” For other interventions, he simply tells the parents what will be done, such as, “He’ll get a vitamin shot today to prevent any risk of bleeding.” Given the similarities across these interventions – all are accepted as usual care because they are low-risk and have been shown to improve health – he wonders why he engages parents in such different ways, and if SDM is even appropriate to use for these interventions at all.
Exploring the Boundaries of Shared Decision-Making
Answering these questions is a current focus of Opel’s research. A first step is determining what elements of a decision are needed for SDM to be appropriate. Opel explains, “One proposed requirement for using shared decision-making is that the decision at hand needs to include more than one medically acceptable option. If there is only one medically acceptable option, there really is nothing to ‘share’ and I don’t think shared-decision making therefore makes much sense.” A requisite next step in this deliberation, then, becomes determining what constitutes a “medically acceptable” option, which is a weighty task in itself.
Another problem is how SDM should look when the patient is a child. If a reason to use SDM is to elicit the patient’s preferences so that their decision best matches those preferences, Opel thinks an important question to consider is whether or not SDM should look different if the person with the preferences is the parent. Opel suspects that implementing SDM in pediatrics will not be the same as in adult medicine because there are constraints on a parent’s or surrogate’s authority on behalf of a child that don’t exist for adults making medical decisions for themselves.
With support from the Greenwall Foundation, Opel seeks to answer these types of conceptual questions by exploring how SDM should look in the fields of pediatrics, public health and preventive care. He thinks that without more conceptual work to fill in current gaps in our understanding of SDM, clinicians will continue to have trouble knowing when it is appropriate to use SDM and when it is not. Opel fears that this results in him sometimes using SDM when it is not appropriate and not using it when it is. The Greenwall research project allows for dedicated time in which Opel can do this conceptual work and help delineate how SDM should be applied in different contexts.
The Greenwall Foundation’s Faculty Scholars Program in Bioethics selects up to five junior faculty members nationally for three years of funding. Innovative research projects are chosen that will address pressing ethical issues, improve patient care, inform biomedical research or enhance public policy.
"There are lots of routine, preventive care recommendations in pediatrics, and despite parallels among them – they are universally recommended, all have strong evidence base, benefits outweigh burdens, all are standard of practice – I approach them differently. Some I use shared decision-making, yet for other, similar recommendations, I convey the plan in a way that limits parental input. Why do I handle interventions with similar attributes differently? If there is good reason, what are those reasons? I don’t think we’ve answered these questions, so this is an area of focus in my research."