Have you been involved in shared-decision making?

A recent study published in the British Medical Journal (BMJ) proposes a simple three talk model for shared-decision making in the clinic. 

Have you been involved in a shared-decision making process, or have you simply been told what is best for you? 

Please have your say.

My problem is that in reality, very few MSologists practise shared-decision making. They tend to pay lip service to it. For example, I recently co-chaired a teaching course during which we discussed several case scenarios. The objective was to select an appropriate DMT for the cases presented. The problem is that none of the patients were in the room, so how could we engage them in shared-decision making? In other words, you make a decision for the patient and then you encourage them to agree with you. This is called paternalism

The model is simple enough and should be easy to implement:
  1. Team Talk: Let’s work as a team to make a decision that suits you best.
  2. Option Talk: Let’s compare the possible options.
  3. Decision Talk: Tell me what matters most to you for this decision.

Elwyn et al. A three-talk model for shared decision making: multistage consultation process. BMJ 2017;359:j4891

Objectives: To revise an existing three-talk model for learning how to achieve shared decision making, and to consult with relevant stakeholders to update and obtain wider engagement.

Design: Multistage consultation process.

Setting: Key informant group, communities of interest, and survey of clinical specialities.

Participants: 19 key informants, 153 member responses from multiple communities of interest, and 316 responses to an online survey from medically qualified clinicians from six specialities.

Results: After extended consultation over three iterations, we revised the three-talk model by making changes to one talk category, adding the need to elicit patient goals, providing a clear set of tasks for each talk category, and adding suggested scripts to illustrate each step. A new three-talk model of shared decision making is proposed, based on “team talk,” “option talk,” and “decision talk,” to depict a process of collaboration and deliberation. Team talk places emphasis on the need to provide support to patients when they are made aware of choices, and to elicit their goals as a means of guiding decision-making processes. Option talk refers to the task of comparing alternatives, using risk communication principles. Decision talk refers to the task of arriving at decisions that reflect the informed preferences of patients, guided by the experience and expertise of health professionals.

Conclusions: The revised three-talk model of shared decision making depicts conversational steps, initiated by providing support when introducing options, followed by strategies to compare and discuss trade-offs, before deliberation based on informed preferences.


About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.


  • I was given a small booklet to read & a week to decide which DMD I'd like to start on. It seemed like she was very open to me making my own choice but she was very opinionated about which one is the best to start with/which would she would not consider (which is fine – she knows "better" anyways).

    We discussed a couple of things such as side effects, how long I should be on a specific DMD, what happens later on…

    HOWEVER, I consider myself very "demanding" and active so I'd just say she entertained it not sure how it usually goes ha ha

  • I think I had "shared decision making". After a second relapse I was offered, a choice of plegridy, GA or DMF. I was told Women "my age" couldn't have teriflunomide, and that all other dmts were second line. I was told that from the dmts I was offered they all had the same efficacy, but the AEs differed.

    I felt it was a conversation about side effects and convenience opposed to efficacy. I've read this blog for years so I felt this was a simplistic overview of dmts. My priority has always been efficacy, so I suppose I was a bit disappointed that it wasn't really discussed.

    I feel like my experience of shared decision making was a bit of a token gesture, aimed at making me more compliant and possibly more jovial whilst trying to deal with the side effects…

    I dislike the term shared decision making. I put it in the same bs bucket as "patient journey".

    How "shared" is a decision when you (the doctor) choose to open the conversation, you choose what treatments to discuss, and the final decision is yours. Any attempts I make to direct the conversation just lead back to your original suggestions.

    It's founded on a sleight of hand. It's intended to make me feel like i have a choice when really it's all much of a muchness.

    I'm not saying I want to have more choice… As a neurologist you've spent a little bit of time on your education and you probably know what's best for me.

    My suggestion would be scrap the term "shared decision making". Its not realistic. The decision is not really shared and never will be, the decision is mainly yours yet the consequences are entirely mine. As a term it's annoyingly corporate, and feels ridiculously PC in a world where you refer to me as "your patient" (the latin translate being: your sufferer).

    Thanks as always

  • For me the most emotive word in this post is "team". Ros and I have come, over the 22 years o my MS to use this word to refer to all the different health professionals that were involved in my care.

    Without exception we experienced "shared decision making" and, on reflection, I think that is because we, as patient and carer, expected that. My feeling is that many, especially those older or less educated (PhD) than me still subscribe to "doctor knows best"

    That, and the enormous presence of "Dr Google", would be what I would suggest as the next steps in this research.

By Prof G



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