Galasiński Dariusz, Ziółkowska Justyna, Elwyn Glyn
Centre for Interdisciplinary Research into Health and Illness,University of Wrocław, Św. Jadwigi 3/4, 50-266 Wrocław, Poland.
University of Social Sciences and Humanities, ul. Ostrowskiego 30b, 53-238 Wrocław, Poland.
Patient Educ Couns. 2023 Jun;111:107681. doi: 10.1016/j.pec.2023.107681. Epub 2023 Feb 24.
There is little evidence that share decision-making (SDM) is being successfully implemented, with a significant gap between theory and clinical practice. In this article we look at SDM explicitly acknowledging its social and cultural situatedness and examine it as a set of practices (e.g. actions, such as communicating, referring, or prescribing, and decisions relating to them). We study clinicians' communicative performance as anchored in the context of professional and institutional practice and within the expected behavioural norms of actors situated in clinical encounters.
We propose to see conditions for shared decision-making in terms of epistemic justice, an explicit acknowledgment and acceptance of the legitimacy of healthcare users and their accounts and knowledges. We propose that shared decision-making is primarily a communicative encounter which requires both participants to have equal communicative rights. It is a process that is started by the clinician's decision and requires the suspension of their inherent interactional advantage.
The epistemic-justice perspective we adopt leads to at least three implications for clinical practices. First, clinical training must go beyond the development of communication skills and focus more on an understanding of healthcare as a set of social practices. Second, we suggest medicine develop a stronger relationship with humanities and the social sciences. Third, we advocate that shared decision-making has issues of justice, equity, and agency at its core.
几乎没有证据表明共同决策（SDM）得到了成功实施，理论与临床实践之间存在显著差距。在本文中，我们审视共同决策，明确承认其社会和文化背景，并将其作为一系列实践（例如沟通、转诊或开处方等行为以及与之相关的决策）来进行研究。我们将临床医生的沟通表现置于专业和机构实践背景以及临床诊疗中行为者预期的行为规范之下来进行研究。
我们建议从认知公正的角度来看待共同决策的条件，即明确承认并接受医疗保健使用者及其叙述和知识的合法性。我们提出，共同决策主要是一种沟通交流，要求双方参与者拥有平等的沟通权利。这是一个由临床医生的决策启动的过程，需要暂停其固有的互动优势。
我们所采用的认知公正视角对临床实践至少有三点启示。第一，临床培训必须超越沟通技能的培养，更多地关注将医疗保健理解为一系列社会行为。第二，我们建议医学与人文科学和社会科学建立更紧密的关系。第三，我们主张共同决策的核心问题是公正、公平和能动性。
