CECSCenter for the Evaluative Clinical Sciences at Dartmouth
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Health Care Decision Making  

The tradition of medical decision making based on professional paternalism does not deal well with the complex trade-offs created by modern technology. Rates of elective surgery and other discretionary interventions are determined in large part by practice style and, sometimes, by geographic variation in resources. These rates should be determined by the choices informed patients make. Patients should understand what is known, as well as what is not known, about the outcomes that matter to them. The outcomes commonly vary according to the treatment used. Patients should be able to make informed choices according to their own treatment preferences.

While there is a growing interest on the part of patients in challenging the paternalistic role of physicians as agents and sole decision makers, there are economic forces that have pulled in the opposite direction. Employers, as payers, have promoted the use of managed care, which challenges the autonomy of physicians but sometimes imposes its own rules on clinical medicine, and substitutes the managed care company for the physician as the decision maker. This transfer of agency power to third parties - payers, insurance companies, and health maintenance organizations - challenges the role of the patient in the choice of medical care.

A different model of the doctor-patient relationship is emerging in response to this rebellion against both paternalism and third party intrusion into medical decision making. Shared decision making recognizes that there are complex trade-offs in the choice of medical care. Shared decision making also addresses the ethical need to fully inform patients about the risks and benefits of treatments, as well as the need to ensure that patients' values and preferences play a prominent role. Most patients willingly participate in shared decision making, even when decisions are complicated and difficult.

Shared Decision Making Initiatives
  • Summer Institute in Informed Patient Choice
    Patients who are choosing among competing health care interventions face an extraordinarily complex psychological challenge. So far, fundamental and applied investigators have successfully studied different aspects of this multi-faceted process. However, many research questions remain unanswered, and may best be solved by the collaborative efforts of multi-disciplinary scientific teams. The Institute's participants - advanced graduate students, research fellows, postdoctoral fellows, and junior professors - will debate how new insights in the fundamental decision sciences can guide future applied work in patients' decision support/decision aids, and how observations gained from applied work in patients' decision support/decision aids can point to new fundamental theories in human judgment & decision making.

  • Health Decision Research
    The mission of Health Decision Research is to provide a scientifically rigorous and ethically sound basis for effective decision making in preventive, screening, diagnostic, treatment, clinical trials, and palliative contexts.

  • Center for Shared Decision Making
    The Center for Shared Decision Making is a resource center at Dartmouth-Hitchcock Medical Center, providing information, including a number of video and audiotaped decision aids to people making health care decisions.

  • Foundation for Informed Medical Decision Making
    Research indicates that patient preferences are often less important in treatment decisions than factors having little to do with patients or their illnesses. The mission of the Foundation for Informed Medical Decision Making is to focus on the role patients play in selecting treatments for their medical conditions.