In a recently releases Monthly Features article in Pediatrics, Dr. Christopher Gaw discusses how trainees can be involved in advancing shared decision making (SDM) in pediatrics (10.1542/peds.2017-1772). Dr. Gaw’s thoughts are incredibly timely. A quick look for any articles in Pediatrics in 2017 that address SDM brought up 6 additional manuscripts on such diverse topics as the febrile infant, children with disabilities, children with hearing impairment, and seriously ill children. Additionally, the AAP released a Policy Statement in 2016 on Informed Consent in Decision-Making in Pediatric Practice (10.1542/peds.2016-1484) which includes information about the role of shared decision making. A now 2 year old systematic review (Wyatt et al Academic Pediatrics 2015) concluded that, “A limited evidence base suggests that pediatric SDM interventions improve knowledge and decisional conflict, but their impact on other outcomes is unclear.” We are in the infancy of SDM in pediatrics: enthusiasm is high and evidence is starting to pour in.
Medicine has slowly but wisely begun to turn its back on paternalism in order to embrace SDM. Many might reasonably feel that we have been practicing SDM on a daily basis without attaching a fancy moniker to the day in-day out dialogues that we have with the families we serve. Simply asking about the formulation of amoxicillin that the family and child prefer (do you think a chewable, liquid or swallow pill will be easiest?) is SDM, but clearly we can take this several steps further. As Dr. Gaw suggests, one is to formalize the process using decision aids, and another is to push the discussion into more meaningful and difficult conversations about diagnostic testing, optimal treatments and outcome planning that were traditionally seen as only the “physician expert’s” province. Increasingly we have recognized that the parent is truly the expert on their child, and that parents want preventive health care that acknowledges this (Radecki et al Pediatrics 2009). Extending this model to pediatric disease care, a recent initiative seeks to include the views and ideas of parents in Clinical Guideline development for children with rare diseases (Khodyakov D, et al, JMIR Research Protocols, 2017), while another study validated the critically useful contribution of both parents’ and adolescents’ views and ideas in the process of identifying mental health disorders (Aebi M, et al. Child Adolesc Psychiatry Ment Health. 2017).
Dr. Gaw’s article brings us right to the bedside of a 4 month old with bronchiolitis whose family reasonably pushed back at the medical team’s recommendations. I agree with him that SDM could have had a meaningful and helpful role in the scenario he described. I am also very enthusiastic about his vision that trainees can be encouraged to find a niche, be it through advocacy, education, quality improvement, research, or direct clinical care, to push SDM forward, to conduct research on SDM, and if results are as positive as they seem, to make it our default approach in pediatrics.
