Shared Decision Making (SDM) has been defined as “…an approach where clinicians and patients make decisions together using the best available evidence” . An ethical imperative is found at the heart of patient centred care, a paradigm in which clinicians and patients work together using best available evidence to agree a fully informed plan for that patient’s treatment or care . The process requires equal collaboration of both parties, with patients actively encouraged to deliberate on information presented to them and to communicate their personal preferences to the clinician . A good therapeutic relationship and a supportive environment are pre-requisites for patients to: understand information presented to them; explore what is important to them; deliberate on all available options and express themselves openly .
Patients’ desires to be involved in decision making were first identified in the mid-1970s , but the concept of SDM was only articulated in 1999 . Since then, SDM has been the subject of ongoing discussion, research and policy initiatives across the developed world .
There are many reported benefits of using SDM as a clinical tool; SDM adept clinicians are able to collaborate with their patients and note improvements in: health outcomes and reduced referrals for clinical testing ; improved patient satisfaction and adherence to treatment  as well as increased patient autonomy and engagement . A number of negative practitioner beliefs/perceptions have also been identified: SDM takes too much time; patients do not want to be involved in decision making  and giving patients power to decide is an abdication of professional duty . These beliefs may partly be related to when practitioners were trained: those qualifying before SDM was introduced are more likely to adopt a ‘doctor knows best’ approach to patients .
Paradoxically though, despite professional pressures on clinicians to use SDM, patients may not actually be interested in evidence based medicine; anecdotes appear to trump scientific evidence . Ironically, patients may appear quite resistant to engaging with SDM and Towle et al.  identified a number of barriers including: satisfaction with the existing relationship leading to a low motivation for change; perceptions that change is outside of a patient’s control; change will risk any existing rapport; a lack of skills required to change communication patterns. Additionally, patients often feel vulnerable given that clinicians are generally more knowledgeable, or are perceived as such, and thus hold power in the relationship . Rectifying this power imbalance requires greater patient knowledge and is reliant on clinicians preparedness to give patients the opportunity to be involved .
Poor general health of a patient and cognitive impairment such as dementia have been identified as non-modifiable factors that impact on SDM engagement . Poorly modifiable patient factors include low health literacy, low numeracy or patients who come from culture backgrounds that discourage autonomous decision making . In some cases, decision making may include opinions and beliefs of family and/or friends, adding additional layers of complexity to engagement with SDM . Finally the impact of media, social and otherwise, may also impact on patient’s willingness to engage with SDM .
Within the United Kingdom, the National Institute for Health and Care Excellence has adopted SDM as a quality standard, stating patients must be “actively involved in shared decision making and supported by healthcare professionals to make fully informed choices about investigations, treatment and care that reflects what is important to them” . The components of SDM include: 1) Define the problem to be addressed; 2) Present the options; 3) Patient and clinician discuss pros and cons of each option to include; 3a) Clinicians knowledge about risks, benefits, costs, convenience; 3b) Patients ability or self-efficacy in following through with tests, medications, procedures, required behavioural changes, referrals . It is also important to recognise that SDM is a process and Makoul et al. (2006) go on to state, ‘it is essential that physicians and patients arrange follow-up to track the outcome of decisions that have been made or reach resolution on those that have not’.
The United Kingdom’s National Health Service provides healthcare to the populace and estimates suggest that over a million patients are seen by the National Health Service every 36 h . In 2009, the National Health Service published their constitution, part of which committed to provide patients with sufficient information for them to be able to participate in discussions and decisions regarding their care , which embeds SDM into the National Health Service via the ‘Right Care Shared Decision Making Programme’ . Similarly, the General Medical Council, the statutory regulatory body for United Kingdom medical doctors, obliges doctors to work in partnership with patients by listening to their concerns and preferences, providing them with the information they need, in a way they can understand, in order to make a joint decision about their treatment or care . Although the current Standard of Proficiency for United Kingdom physiotherapists published by the Health and Care Professions Council, contains no explicit requirement for SDM , physiotherapists working within a National Health Service setting would be obliged to commit to the National Health Service’s ‘Right Care Shared Decision Making Programme’.
Self-determined United Kingdom patients do selectively seek complementary care outside of the National Health Service, with osteopaths being one of the regulated healthcare professionals who are sought out; some of whom are contracted to work within the National Health Service . The 5000 United Kingdom osteopaths carry out approximately seven million encounters a year and are statutory regulated by the General Osteopathic Council . The General Osteopathic Council are responsible for setting the professional standards and codes of practice for the United Kingdom osteopathic profession. The current Osteopathic Practice Standards came into force in September 2012 and is nearly identical to General Medical Council’s guidance on good medical practice. Within the Osteopathic Practice Standards, the concept of SDM is explicitly referred to; standard A5 states that osteopaths must “work in partnership with patients to find the best treatment for them”; guidance note 1 states, “You should encourage patients to ask questions about their treatment and to take an active part in the treatment plan and any decisions that need to be made ”. This obligation remains within draft revised guidelines (relisted as A3.2) that are scheduled for publication in September 2019.
As a statutory regulator, the General Osteopathic Council is responsible for handling patient complaints about osteopaths. Complaints are screened, investigated and if certain threshold criteria are reached, ultimately heard by a panel of the Professional Conduct Committee. In 2014 incidence rate of concerns raised were < 0.004% and the number of serious cases heard by the Professional Conduct Committee panel involved < 1% of United Kingdom registered osteopaths . The largest component of patient concerns raised are about professional conduct, which includes ‘no shared decision-making with the patient’  Despite the most recent Figs. (2017) showing a five year low in the number of patient complaints and concerns against United Kingdom osteopaths, failures in professional conduct including shared decision making remains the largest component .
The General Osteopathic Council is also responsible for validating Osteopathic Educational Institutes’ training of undergraduate students, ensuring they reach the prerequisite level of competence set out within the Osteopathic Practice Standards, to be able to join the register. Clinician training traditionally focuses on embedding problem-solving communication skills, which are different from those required for SDM behaviours. Problem solving training enables novice clinicians to focus on diagnosis formulation and patient management planning, but once acquired these forms of communication skills may become habitual and difficult to change in the future . Whist embedding explicit SDM training into a clinician’s early medical education should ensure that appropriate SDM behaviours become the norm for these future medics, there is some evidence that even if medical students are taught SDM at undergraduate level, once they become mentored by mature clinicians, they may adopt that clinician’s style of communications, including any ‘bad habits’ (non SDM behaviours) .
There is some preliminary evidence suggesting a relationship exists between the exit degree level of undergraduate osteopathic education, a practitioner’s conception of practice and an osteopaths’ engagement with SDM behaviours: the latter being categorised as either ‘clinician-led’, ‘patient-led’ or ‘shared’ . Although SDM behaviours have been assessed across a range of other health professional settings and across a number of countries , the extent to which United Kingdom osteopathic students use SDM within clinical encounters is currently unknown. At the time that this study was conducted, SDM was not an explicit topic within the syllabus of the Osteopathic Educational Institute, although the concepts and practicalities of enhancing patient communication and obtaining consent had been taught to the clinical students taking part in this study.
Nonetheless, in their systematic review, Couët et al. noted that those studies which included an intervention designed to improve qualified clinicians’ SDM behaviours, all showed positive improvements in post-intervention O12 scores; ‘interventions’ included the introduction of decision aids as well as training .
Additional external pressures on adoption of SDM behaviours have been identified and include commercial, regulatory and legal pressures on practitioners. There is a shift toward viewing the patient as a ‘consumer’ and an acknowledgement that patients are now often ‘informed’ about their problems even prior to consultation with a practitioner . A 2014 United Kingdom Supreme Court found a case of medical negligence proven and in doing so reviewed the duty of disclosure a doctor has towards a patient. Known as the Montgomery Precedent, it outlines the rights of patients to be told of ‘material risks’ inherent in a treatment in order for the patient to be able to make an informed decision about whether they wish to incur those risks . Materiality was defined as “whether a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it.” .
In 2014, Jones et al published a study that used a validated instrument to determine the degree to which 12 National Health Service physiotherapists (including ‘newly qualified’ or Band 5 practitioners) working in a hospital setting, used SDM behaviours . The publication included score data obtained from the instrument that was detailed enough to allow any future studies to be able to make a comparison with their data. We therefore aimed to replicate the study in so far as we used the same tool and method of capture. This allowed us to both determine the degree to which clinical students within one United Kingdom Osteopathic Educational Institute’s teaching clinic used SDM and also statistically compare these to Jones et al.’s data.