Shared Decision-Making in Screening

Shared decision-making is a process in which clinician and patient together weigh the benefits and harms of a screening test against the patient's values and circumstances, rather than the clinician deciding alone. It is especially important for screening choices whose net benefit is small or uncertain, where reasonable people, well informed, may choose differently.

Definition

Shared decision-making in screening is a collaborative process in which the clinician conveys the evidence on benefits, harms, and uncertainties of a screening option, the patient conveys their values and preferences, and the two reach a screening decision together, often supported by structured decision aids.

Scope

This topic covers the rationale for shared decision-making in screening, the steps of the process, the role of decision aids and balanced risk communication, and the screening contexts in which it is most relevant. It is presented as a methodological and communication topic; it does not prescribe whether any individual should accept or decline a given screen.

Core questions

• Why are some screening decisions preference-sensitive rather than clearly beneficial for everyone?
• What steps make up a shared decision-making conversation?
• How can the benefits and harms of screening be communicated without bias?
• What are decision aids, and what effect do they have on screening choices?
• In which screening situations is shared decision-making most strongly indicated?

Key concepts

• Preference-sensitive decisions
• Choice talk, option talk, and decision talk
• Balanced presentation of benefits and harms
• Absolute versus relative risk communication
• Decision aids
• Patient values and informed choice
• Decisional conflict

Mechanisms

Shared decision-making typically unfolds as choice talk (signalling that a choice exists), option talk (describing the options and their benefits and harms), and decision talk (eliciting and integrating the patient's preferences), as set out in the model of Elwyn and colleagues (2012). Effective risk communication presents outcomes in absolute numbers and natural frequencies and frames benefits and harms symmetrically, since formats can otherwise bias choices, as reviewed by Zipkin and colleagues (2014). Decision aids structure this exchange with explicit probabilities and values clarification, and the Cochrane review by Stacey and colleagues (2017) finds they increase knowledge, improve accuracy of risk perception, and reduce decisional conflict.

Clinical relevance

Screening decisions such as whether to undergo prostate-specific antigen testing or when to begin or stop certain cancer screens often have a small or uncertain net benefit, so the right choice depends on how a person weighs early detection against false positives, further testing, and overdiagnosis. Shared decision-making is the recommended approach for these preference-sensitive situations. This entry describes the process and its evidence; it is not itself advice about whether to be screened.

Evidence & guidelines

Decision aids have been evaluated in a large Cochrane systematic review showing improved knowledge and risk perception and reduced decisional conflict without increasing anxiety (Stacey et al., 2017), and evidence-based principles for communicating risk have been synthesized by Zipkin and colleagues (2014). Major guideline bodies, including the US Preventive Services Task Force, recommend shared or informed decision-making for several screens whose benefit is finely balanced. The conceptual foundations are the model articulated by Elwyn and colleagues (2012) and the earlier definitional work of Charles and colleagues (1997).

History

Shared decision-making was articulated as a distinct model in the 1990s, with Charles and colleagues (1997) defining its essential features, and was formalized into a practical three-step model by Elwyn and colleagues (2012). Its application to screening grew as evidence on overdiagnosis and the small net benefit of some screens made clear that a single recommendation could not fit all patients, and as decision aids accumulated trial evidence.

Debates

Can shared decision-making be delivered within routine practice constraints?

Genuine shared decision-making takes time, skills, and tools that busy clinical encounters may lack, raising questions about how to implement it at scale and whether decision aids can substitute for or support clinician conversations.

Does framing of risk steer screening choices?

How benefits and harms are presented, in relative versus absolute terms or with different reference points, can shift the choices people make, so achieving truly balanced communication is a methodological challenge rather than a solved problem.

Key figures

• Glyn Elwyn
• Cathy Charles
• Dawn Stacey
• Michael J. Barry

Seminal works

• elwyn-2012
• charles-1997
• stacey-2017

Frequently asked questions

Why is shared decision-making recommended for some screening tests but not others?

When a screen clearly does much more good than harm, a straightforward recommendation suffices; shared decision-making is reserved for preference-sensitive choices where the net benefit is small or uncertain and depends on how a person values early detection against harms such as false positives and overdiagnosis.

What is a decision aid?

A decision aid is a structured tool, such as a leaflet, video, or interactive program, that presents the options and their benefits and harms in explicit terms and helps a person clarify what matters to them; systematic-review evidence shows decision aids improve knowledge and risk perception and reduce decisional conflict.