3 key psychological obstacles to shared decision-making in healthcare
Shared decision-making (SDM) between doctors and patients has long been regarded as a cornerstone of patient-centred care. By encouraging collaboration, understanding, and mutual respect, SDM empowers patients to actively engage in decisions about their health.
However, despite its potential, effective SDM is rare.
Why?
This article describes three key psychological reasons:
1. Social desirability bias
2. Projection bias
3. Attachment styles
Let’s begin by looking at the first of these - social desirability bias…
1. Social desirability bias
Social desirability bias refers to the tendency for individuals to present themselves in a way that they believe is socially acceptable or favourable – rather than expressing their true preferences or concerns. This bias can be evident in both patients and doctors, and is our first key obstacle to effective SDM…
Patients:
First, for patients, a strong desire to please, or to avoid conflict with their doctor may lead them to agree with treatment options they do not fully understand or want. For example, a patient might say yes to a recommended treatment because they want to appear cooperative or because they fear disappointing their doctor.
Alternatively, social desirability bias can cause patients to under-report symptoms, habits and behaviours they feel are undesirable. Patients may also over-report preventive measures they’ve taken. In all three cases, patient social desirability bias is conspiring to reduce the likelihood of effective SDM.
Doctors:
Similarly, doctors may also exhibit social desirability bias by tailoring their advice to what they think the patient wants to hear. A doctor might offer a treatment option in a way that aligns with the patient's expectations or assumptions, even if it’s not the most appropriate choice. This can over-inflate patient expectations of success, and lead to an undermining of patient respect for doctors.
Let’s next look at challenge number two…
2. Projection bias
The second key psychological obstacle to SDM is projection bias. This describes people’s frequent and mistaken assumption that their tastes or preferences will remain the same over time. For example, someone may ultimately find they have vastly over-estimated the effect of a career promotion on their happiness.
Critically, while we often incorrectly project our current thoughts and feelings onto our future selves, we also do this when it comes to trying to understand others…
Patients:
First, patients may project their own emotional experiences onto the doctor, and assume the doctor feels the exact same way as they do about the diagnosis, prognosis, or treatment options. For example, a patient who feels devastated by a diagnosis might incorrectly believe that their doctor shares their sense of hopelessness when this may not be the case. This emotional disconnect can hinder the open communication, understanding, and respect required for effective SDM.
Doctors:
Similarly, doctors may well have difficulty appreciating a patient’s emotional state: for example, the levels of fear, anxiety, or uncertainty they are experiencing. No matter how educated and motivated doctors are when it comes to the principles of SDM, projection bias makes the task of truly understanding how a patient feels almost impossible. This represents a significant obstacle to effective SDM.
3. Attachment styles
Finally, attachment theory, developed by John Bowlby, explains how our early relationships with caregivers influence our patterns of behaviour and emotions in adult relationships. This theory is also highly relevant to interactions between doctors and patients, where attachment styles can particularly affect the engagement of both parties in shared decision-making...
Patients:
First, the good news is around 6 in 10 patients are believed to have an attachment style known as “secure”. However, this leaves 4 in 10 patients with an “insecure” attachment style...
What does this mean for SDM? Well, this “insecure” group may first find it difficult to open up to doctors…leaving doctors with limited insight into the patient’s concerns or values.
Alternatively, other patients with an insecure attachment style may have an overly dependent relationship with their doctor, seeking excessive reassurance and approval. These patients may rely on the doctor to make decisions on their behalf – rather than engaging in the decision-making process themselves.
Doctors:
However, doctor attachment style can also cause issues. For example, doctors with low trust in others may struggle to engage patients in SDM. Further, considering attachment styles of both parties, clashes in attachment style may be especially destructive. For example, when those same doctors with low trust in others encounter patients with similarly low levels of trust in others.
Conclusion
Shared decision-making holds great promise for improving patient care by promoting collaboration and respect. However, it is key to recognise that psychological obstacles such as social desirability bias, projection bias, and differing attachment styles can severely endanger the process. These obstacles may lead to miscommunication, reduced patient engagement, and decisions that do not truly align with the patient’s preferences and values.
Addressing these challenges requires both doctors and patients to be aware of the psychological factors at play. By overcoming these obstacles, SDM can be more effective in fostering better health outcomes and enhancing patient satisfaction.