Shared Mind: Communication, Decision Making, and Autonomy in Serious Illness

In 1979, Gregory Bateson defined mind as a systems phenomenon which is characteristic of living organisms, societies, and ecosystems and has the ability to process information, think, learn and remember.(1) His conceptualization contrasted sharply with the commonly accepted view that mind was simply matter possessed solely by an individual.

Family medicine has shared a real affinity with Bateson’s notion. It has envisioned the unit of care not only as the individual patient but as the complex relationships among multiple systems--within and beyond the skin. However, recent developments in the practice of healthcare signal the need for a dramatic reorientation to our core vision, and Epstein and Street have done just. Through their articulation of the shared mind, they have provided a framework for how relational systems actually operate during clinical encounters. By highlighting the processes of sharing knowledge, deliberation, and decision-making, the authors have captured how the network of relationships becomes its own system, connected to and unique from the other subsytems involved. They bring an amorphous concept to life.

Most recently, our systemic core beliefs have been challenged by some of the ways in which the Patient Centered Medical Home has been operationalized. Current technologies can unwittingly shuttle us away from being attuned to relationships and to focus on the individual patient out of context (e.g., Electronic Health Records that make charting family information difficult; self management strategies that deemphasize the family and social relationships). In the midst of the rushed office practice, simple tools to engage individual patients can become quite attractive. Yet, we run the risk of functioning primarily in what Epstein and Street describe as the transactional approach. We have seen this in how shared decision-making can be frequently boiled down to a set of step- by- step behaviors. This methodology becomes easy to document in practice and to teach future physicians. However, some research suggests that patients and clinicians can go through the requisite motions and yet not meaningfully engage if they do not experience a real relationship of collaboration and mutual trust.(2,3)

When the transactional approach becomes dominant, rather than one point on a continuum, physicians and patients have a limited ability to learn and evolve, which is so important in continuity relationships where important care decisions must be made. The transactional approach positions the physician as the expert, emphasizes control, promotes patients’ passivity, privileges rationality over emotion, and maximize success at all costs. For “shared mind” systems to function effectively and autonomously, however, they must learn to nurture respect for shared expertise, foster experimentation, facilitate mutual trust, actively allow conflict and difference, accept uncertainty, share control of the process, develop capacity for reflection and action and commit to collaborate.(1,4)

To fully grasp the power of Epstein and Streets’ mapping of the shared mind, I would hope that we read and reflect on their article with each other in journal clubs, practice groups and research seminars. By fostering a “shared mindfulness”, we can reclaim our legacy and further evolve clinically effective and meaningful relationships for our patients, families and ourselves.

References

1. Bateson, G. Mind and nature: a necessary unity (advances in systems theory, complexity, and the human sciences. New York: E. P. Dutton, 1979.

2. Saba GW, Wong ST, Schillinger D, et al. Shared decision making and the experience of partnership in primary care. Ann Fam Med. 2006;4(1):54- 62.

3. Hauer KE, Fernandez A, Teherani A, Boscardin CK, Saba GW. Assessment of medical students' shared decision-making in standardized patient encounters. J Gen Intern Med. 2011;26(4):367-72.

4. Schön D. Educating the reflective practitioner. San Francisco: Jossey-Bass, 1987.

Competing interests:   None declared