Shared decision making in realistic medicine: what works

Synthesis of recent evidence on the current use of shared decision-making in Scotland, and international evidence of what works in encouraging greater use of shared decision-making in clinical consultations.

Executive Summary

Realistic Medicine puts the person receiving care at the centre of decision-making and creates a personalised approach to their treatment and care. This summary highlights some practical tools, skills and attitudes that can foster and facilitate greater engagement in Shared Decision Making (SDM) and draws on international academic and policy literature with a focus on relevance to Scotland. The objectives of this research were to identify:

  • What we know about shared decision-making in Scotland?
  • What are the existing barriers to further uptake of SDM in clinical consultations?
  • What can be done to encourage greater engagement of SDM in Scotland?

What is Shared Decision-making?

SDM decisions are made utilising both the medical knowledge of the clinician and the personal preferences of the patient. SDM 'represents an important shift in the roles of both patients and clinicians' moving away from 'the doctor knows best' approach with unilateral information transfer, towards more active participation from patients, and support from professionals as curators of information.

What do we already know about SDM in Scotland?

SDM is a key feature of Realistic Medicine, as set out in the Chief Medical Officer's recent Annual Reports (2014/15-2016/17). This evidence review suggests that most patients are keen to receive more information about their healthcare and participate in SDM, and the majority of clinicians are keen to provide this information. However, there was not a dominant patient view on what information would help them to make healthcare decisions, although there was a general preference to be given this information face-to-face. Shifting the culture toward shared decision making will mean shifting the balance of communication in consultations to encourage the exchange of knowledge and information between patients and their healthcare professionals.


The literature highlights several barriers to greater engagement with SDM, namely:

Knowledge barriers:

  • Lack of (clinician) knowledge on how to carry out SDM;
  • Clinician concern that SDM may mean they appear unknowledgeable to patients;
  • Clinician belief that they are already doing SDM;
  • Clinician concern on how to respond to patients who disagree with them;
  • Lower patient health literacy could lead to difficulties in making decisions.


  • Patient concern that participating in SDM may lead to bad or no treatment from clinician;
  • Lack of belief (patient and clinician) that SDM will happen;
  • Inconsistences between how clinicians and patients understand 'a shared decision';
  • Lack of time to participate in SDM;
  • Clinician's assumptions of patient preferences.

Meaningful conversation

  • Lack of recognition of patient-clinician SDM power dynamics;
  • Concern that environment is not receptive to SDM and difficult conversations;
  • Lack of trust/ familiarity between patient and clinician.

What are the key conditions of an SDM process?

The recent evidence identified a number of key conditions to facilitate SDM:

  • Trusting relationships between patient-clinicians supported by organisational practice and culture;
  • Recognition of power imbalances between patient-clinicians;
  • Patients viewed as active participants in their healthcare;
  • A policy climate that appreciates the importance of SDM.

Effective tools, skills and attitudes for SDM

The recent evidence on SDM identified a number of tools, skills and attitudes that can encourage greater SDM engagement. A single example will not be effective in all contexts, but a change in attitudes may be the catalyst as 'skills trump tools, and attitudes trump skills' (Joseph-Williams, et al., 2017, p. 2). Key findings are:





Individual appointment

In-consultation decision aids; recording consultations

Enhancing communication skills of clinicians

Ensuring SDM receptiveness/awareness of clinicians/patients


Identify SDM readiness of local teams; more efficient practices

Training in SDM throughout clinician career

Promotion of SDM through clinical and patient champions


Tools to measure SDM successes; education to raise awareness

Communicating SDM benefits

Leading by example


Clinicians and patients are generally receptive to SDM but the wider system tends to focus on efficiencies (e.g. reducing waiting lists) and this can make practising shared decision-making difficult. The perceived barriers to SDM highlight uncertainties from patients and clinicians around participating in SDM , as many believe they are already doing it or do not attempt it. Training is needed for more effective communication skills (e.g. role-plays on effective SDM). This report identifies several key conditions that need to be present to foster and facilitate SDM and there is a lack of evidence on how to measure and evaluate SDM effectively. Better evaluation of SDM might encourage greater engagement by demonstrating its value and how best to participate in SDM.


The following recommendations require consideration from policymakers, as well as relevant stakeholders at a local and national level:

  • Implementation of tools to measure and evaluate the impact of SDM (e.g. patient and clinician satisfaction, and statistics on waste and variation);
  • Creation of a training programme to improve communication skills of clinicians on how to conduct meaningful conversations;
  • More training and education (for patients, clinicians and boards) to raise awareness of how SDM can be practised (and to highlight the evidence that SDM does not have to add more time to consultations);
  • More public training and education campaigns on how best to discuss: 'what matters to you'; patient preferences; and promote better 'continuity of care';
  • Easy access up-to-date information on benefits/ risks of various treatments, and improved access to information on patient preferences.
  • Identify what information would best help patients make healthcare decisions;
  • Promotion of clinical, and system level (e.g. national-level stakeholders and CMO) SDM champions to promote and foster attitudes that are receptive of SDM;
  • Creation, and maintenance, of a culture that appreciates the importance of SDM. e.g. suite of complementary policies related to SDM and person-centred care.



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