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Adoption of shared decision making into routine clinical settings has been slow. 1 Large scale implementation programmes in the UK have delivered valuable lessons on how best to embed shared decision making, 2 3 4 5 but few programmes have actually considered what helps or stops patients from being involved in healthcare decisions. Organisational and clinician perceived barriers are important, 1 3 6 but shared decision making is unlikely to become the norm if we do not also deal with the barriers that patients perceive. Our recent systematic review of patients' perceptions highlighted deeper rooted attitudes that need to be changed in order to prepare patients for a new type of clinical encounter. 7 Here we highlight the main findings and discuss how to prepare patients for shared decision making.
Patients find it hard to speak up
There is good evidence that attitudinal barriers are hindering progress in implementing shared decision making. 1 7 Even when patients are well educated and well informed, many still find it difficult to use this knowledge to participate meaningfully in decisions about their healthcare. 8 The Francis report into failings at Mid Staffordshire trust revealed that patients often feel prohibited from speaking up, even when they are extremely concerned about safety or the quality of care they are receiving. 9 Online blogs, publications, and social media campaigns (such as #hellomynameis) 10 show that even doctors are not immune to the power imbalance when they become patients, feeling that they represent a disease rather than that they are an individual and aware of a pressure to be compliant and passive. 10 11 12 How then can we expect people to express their preferences about treatment options-especially when they often observe doctors assuming that they can act in their best interests, displaying unquestioned confidence in being able to make the best decision on their behalf?
Knowledge is not enough
The 44 studies in our review of patient barriers suggest that many patients currently feel that they can't participate in shared decision making rather than that they don't want to, as many clinicians believe. Unsurprisingly, having information needs met in an appropriate way was a key facilitator for many patients. If patients do not know about their condition, and they do not...