Shared Decision Making and Motivational Interviewing: Achieving Patient-Centered Care Across the Spectrum of Health Care Problems

For the past 50 years, we have taken radical steps to explore what health care would look like if we focused more on relationship, interconnection, and context and less on reductionism, linearity, and dichotomy. We have struggled with the question: How can we deliver care that recognizes that we are humans first, and clinicians and patients second? In answering this, we have had to acknowledge the complexity and uncertainty of healing and the limitations of our ability to cure. And we can no longer ignore how power, disenfranchisement and vulnerability distance patients from ourselves. To answer these vexing questions, we have developed many robust approaches, models, theories of care and full-fledged specialties (Family Medicine, Family Therapy), and patient-centered care is one of them.

In a bold move, Elwyn and colleagues (1) first provide a guide for how to apply two well-developed patient-centered approaches across a range of clinical problems, and then go further to show how to integrate these approaches within a larger conceptual map of patient-centered care.

Combining clinical methods is tricky business. People have very strong opinions about whether it can or should be done and, if so, when in a field's development it should be attempted. (2) One common approach is eclecticism. An individual clinician decides to use whatever methods seem best to address the patient's need at a given time, and is less concerned whether they conceptually align. Others may prefer to articulate a general epistemology that clarifies underlying values and assumptions about clinical care. From that perspective, they can better delineate the principles and skills of practice, and determine the inclusion or exclusion of new techniques or methods based on how well they fit with their larger theory. One mid-level approach considers how to integrate well established methods that, on the one hand, share some important characteristics and, on the other, relate to a broader theoretical perspective. Elwyn and colleagues seem to take this latter approach to integration.

They take great care to succinctly provide the distinctness of the histories, methodologies, and effectiveness of their approaches to decision making and behavioral change. They also show how both approaches operate in conjunction with one another, and how they are embedded in similar principles and skills which ground them in patient centered care.

Further, they deftly avoid falling into the common traps of model integration: reductionism (overly rigid separation of the approaches, principles or skills) and holism (merging the approaches as more or less the same). Because of this, we can study their map and compare it to our experience of the territory:

* Do we agree or quibble with their definitions of the patient- centered care, shared decision making, and motivational interviewing? For example, both patient-centered care and shared decision making have enjoyed decades of debate on what we mean by either approach. The authors recognize the necessity to have clear definitions to ensure optimal outcome, permit rigorous research, and guarantee fidelity of training; (3)

* Do we have alternate models of decision making and/or behavior change to offer? Some may propose other robust models of behavior change (Family Based Treatments, Cognitive Behavioral Therapy);

* What values guide their overall integration? A natural fit would be Epstein and Street's articulation of the values underlying patient centered care. (4) Clarifying fundamental values and assumptions that underlie our approaches will deepen the discussion and guide future model development;

* How does their integration address complex relational issues of power, fear of disclosure, and conflict that sometimes operate in clinical encounters? We have clear evidence that patients, even working with the best intentioned clinicians, are reluctant to reveal if they disagree or have questions. How does this model of integration address these often hidden dynamics and how do we account for them in ours?

* How do we apply their proposed integration within the current constraints of clinical care? How does the increased presence of computers in exam rooms change the relationship; how much time do clinicians have to engage in shared decision making and motivational interviewing; how are other members of the health care and patient team (nurses, coaches, family members) involved; or how much training is required to ensure implementation of the combined approaches?

How can this model integration identify the next steps-in clinical practice, theory-building, research and training? For example, both approaches (shared decision making and motivational interviewing) delineate specific behaviors for clinician and patient. This behavioral focus aids both assessment and training: researchers can determine whether the approach is correctly implemented, and faculty can articulate a coherent set of skills and evaluate if learners use them in clinical encounters. We have had sufficient experience with both approaches to realize how the larger biomedical context often nurtures a reductionistic implementation. Because of their effectiveness, both have been successfully introduced into medical training. However, learners in their eagerness to become competent and armed with an effective treatment can sometimes view them as "techniques" rather than approaches that must be grounded in meaningful relationships. Some of the same learners, months or years later, bemoan that they "MI'd their patient" to no avail or "tried SDM and it didn't work". More work needs to be done on how to help learners fully understand and build the relationships needed for the efficacy of both of these approaches. Training over time, live supervision of clinical encounters, and helping clinicians recall the humanness of their endeavor are just some of the strategies needed to counter the urge for the "short set of communication questions" that will quickly, and artificially, convey trust and caring.

Elwyn and colleagues contend that the progress of patient-centered care depends on valuing shared decision making and motivational interviewing as core elements of good practice. I would also urge us to follow their example and take steps towards continued model building in this area where appropriate. There are many mature and evolving approaches in patient-centered communication, decision making, and behavior change. Rather than developing these approaches in isolation, we would benefit by coming together, comparing notes, seeing where we agree and disagree and further fill out the rich, complex map to guide clinicians, patients and families.

What is bold about this work? The authors have provided a sophisticated lens which reveals who it is that grapples with the hard choices, decisions and changes in clinical care: it is simply us, a group of people who want to help and be helped and, by sharing what we know, work together to maintain hope, allay fear, and heal.

1. Elwyn G1, Dehlendorf C, Epstein RM, Marrin K, White J, Frosch DL. Shared decision making and motivational interviewing: achieving patient- centered care across the spectrum of health care problems. Ann Fam Med. 2014 May-Jun;12(3):270-5.
2. Liddle, HA. On the problems of eclecticism: a call for epistemologic clarification and human-scale theories. Family Process. 1982;21:243-250.
3. Elwyn G, Frosch D, Rollnick S. Dual equipoise shared decision making: definitions for decision and behaviour support interventions. Implement Sci. 2009 Nov 18;4:75.
4. Epstein RM, Street RL Jr. The values and value of patient-centered care. Ann Fam Med. 2011 Mar-Apr;9(2):100-3.

Competing interests: None declared