By Dr. Anthony Policastro

Medicine is often practiced in a paternalistic manner. The physician will make the decision and tell the patient what to do. In many cases this makes sense.

For example, if a child comes in with ear pain and a fever, they likely have an ear infection. When that is confirmed on physical exam, then the appropriate antibiotic is prescribed.

However, not all medical decisions are that simple. I often faced situations with my ADHD patients that could be approached in a number of different ways. 

I could easily have just told the patient what to do. The problem with that is that the patient might not comply with it if they did not agree with me.

I had many adolescent ADHD patients who would come into the office saying their medications were not working. The main reason for this could be that they were not taking their medication. If I asked that question, they would say that they were indeed taking it.

I would then tell them that if their medication was not working I had three choices. The first was to increase the dose. That might be bad if it meant that the dose was too high. The second was that I could switch them to another medication. That might be bad because it might not work as well as the first medication. The third was to add a second medication. That might be bad because there would be two medications with side effects instead of one.

I would then ask them again if they were taking their medication. Most of the time the answer was “no.” That led me down an entirely different pathway. I would ask them why. They might say that they didn’t like the way it made them feel. In that case I would offer a different medication that had less personality effects than the others. Adolescents liked that. It often did the trick.

There is a method called the SHARE approach to treating patients. It has five steps. The first is to SEEK the patient’s participation. Just telling them what to do might not be at all helpful. Summarizing the problem can be helpful.

The second step is to HELP them explore and compare treatment options. In most cases there is more than one way to treat things. They all have risks, benefits and alternatives. The physician’s feeling about risks and benefits might be different than the patient’s feelings. 

It is important in this step to use language that the patient can easily understand. It is also important to make sure the patient understands what you are saying.

The third step is to ASSESS the patient’s values and preferences. This is where the patient gets to discuss those risks and benefits. It is an opportunity to say why he/she prefers one of the options over another. This requires active listening.

The fourth step is to REACH a decision with the patient. This allows input on both sides to come into play. Depending on how complex the decision is, more than one visit might be necessary. It often does not need an immediate decision.

The final step is to EVALUATE the patient’s decision. This means that follow up is necessary to make sure the plan is working. It is important to make sure the patient is able to comply with that particular plan. There might be an opportunity for the physician to help remove barriers.

Clearly this kind of process is not necessary for things like an ear infection in a child. However, as an illness becomes more complex and so do accompanying decisions, there is a great deal of opportunity to be had with an approach like this.