As ASCO this year pursued the theme of “partnering with patients,” it was clear in the abstract submission and selection that researchers in oncology are committed to the pursuit of balancing benefit vs burden of therapy. Both the PROSPECT and SONIA trials, along with many others, propose the opportunity to de-escalate care by demonstrating how current standards of care may add toxicity without significant benefit; whilst multiple studies in early and metastatic setting introduced immunotherapy or targeted therapy as improved alternatives to chemotherapy, escalating care strategically to improve outcomes and reduce toxicity.

However, this puts us at an interesting inflection point in oncology – having clear knowledge that some patients benefit from de-escalating care, being spared unnecessary burden of treatment, and some patients will still need more aggressive modes of therapy to achieve disease control or cure. As such, the conclusion of multiple abstract discussions came to this common point: until we have the biomarkers to identify which patients can receive less vs those who require more, treatment selection will need to be driven by Shared Decision Making (SDM).

What is Shared Decision Making (and equally important – what is it not)?

It is important to understand that SDM is not about empowering the patient to make their own decisions – which some argue is patient abandonment. It is also not a way to get patients to agree to provider recommendations – which some could argue is authoritarian. Instead, it’s a method of interaction between providers and patients with the goal of co-creating solutions for the patient’s unique situation. Integral in this approach is the idea that patient care must account for both biology and biography of the patient – shifting thinking from “how do we treat patients like Pat” to “how do we best treat Pat”.

On the surface, this can seem daunting and at the very least time consuming, but ASCO presenters this year agreed that this is about quality, not quantity of interaction. The focus should be on facilitating unhurried conversations – which does not necessarily mean longer, but instead focused and collaborative conversations. In fact, research presented at ASCO demonstrated that an SDM conversation takes about 20 minutes, approximately the same time required for usual care, and importantly, SDM interactions increased both patient and provider satisfaction!

So where does this fall along the spectrum of care approaches? SDM provides a happy medium of sorts, avoiding pitfalls of the other extremes.

Our in-house Behavioral Science experts, HRW Shift, have examined why HCPs may have a tendency toward one end of this spectrum or the other, identifying multiple unconscious biases. For example, Traditional Paternalism may be driven by ego-threat [1] where the provider feels that, as the expert, they know what’s best for the patient. On the other side, A la carte Autonomy may be influenced by cognitive load [2]and self-preservation [3] with providers being under immense pressure and opting to avoid the burden of the final decision. Similarly, other behavioral science principles can explain successful implementation of Shared Decision Making. SDM helps make the patient’s experience with a product and the eventual outcomes more contextual for them. The act of co-creating solutions fosters a shared Locus of Control[4] for patients and providers, allowing both parties to feel ownership in the decision. This ownership also plays into what is called “the Ikea Effect[5]” where individuals are more satisfied or bought into something they have actively contributed to.

These theoretical benefits have been proven practically and empirically. During a session we attended, they presented a study looking at patients who were delivered ambiguous and unactionable germline genetic testing results – which understandably can raise concerns and cause distress. However, it was the patient’s experience with their provider when discussing those results that was a bigger driver of psychological outcomes. In other words, it’s not necessarily the scary news itself that is psychologically harmful, so much as the interaction between the patient and their provider. We know what happens behind closed doors during these conversations is critical – dialogue research and role play has long been a focus of our clients to help understand this exact dynamic – and now equally important is the understanding how SDM is happening during these interactions.

Challenges & Considerations

Across various sessions we attended at ASCO, we heard repeatedly the importance of setting expectations and being consistent to build trust with patients. However, as culture and technology continue to evolve, it has become increasingly difficult to proactively set expectations before patients can get information on their own, without the benefit of their provider’s input or interpretation. We hear this all the time in research – patients talking about their go-to websites and HCPs lamenting the challenges of “Dr. Google”. However, an under-explored layer to this phenomenon is patients’ engagement with electronic medical records (EMR), including pre-visit test results and post-visit notes. Many of us can admit to being guilty of reading our physician’s notes after a check-up and finding, shall we say “unflattering” descriptions that can change the way we view the relationship between ourselves and doctors. Or have been the patient who got blood work and immediately started googling what different values mean – which always shows the (improbable) possibility of something catastrophic. These things happen all the time, but we also heard firsthand accounts of outcomes much worse than a bruised ego or a mild bout of hypochondria. These patient behaviors contribute to the erosion of trust that is so critical to foster SDM practices. In the strategy we support and the communications we test, we should be thinking of ways we can be supporting both HCPs and patients with the education, communications, and resources that foster SDM practices.  And further, we anticipate that SDM has even greater and farther-reaching implications for market research.

Shared Decision Making in Market Research

Whether we call it SDM or not, we’re already measuring this in many ways in our examination of patient-provider interactions. We see this for example, in dialogue, segmentation, and journey projects, including:

  • Patients’ likelihood of accepting vs. challenging HCP recommendations and the obligation they feel to follow the HCP’s advice vs. advocating for themselves
  • HCPs’ approach to rapport building, unhurried discussions, and/or co-creating solutions
  • Patients’ engagement with information seeking, both self-guided research as well as retrieving results and/or reviewing notes in the EMR – and how HCPs set expectations about information patients may encounter on their own

We also believe there are other ways we can and should incorporate SDM into our research practices. We are working to create novel research solutions, including:

  • Implementing a standardized warm up with HCPs to explore their SDM philosophy. This will provide valuable context in analysis, for example how the materials we may be testing would be used in their practice. Historically in market research, we’ve looked at a spectrum of innovators/early adopters vs. laggards to help discern how materials are processed – but we think HCPs’ place on the SDM spectrum may provide even more value by accessing reality and creating insights that are both strategic and support positive patient outcomes.
  • Adapting the “Think/Feel/Do” framework to account for the duality of the HCP role – as a scientist (the practice of providing care) and as a caregiver to their patients (the disposition of providing care). This exercise is illuminating when asked in the traditional way, but we believe that adjusting this exercise to elicit what HCPs are thinking and feeling from a clinical perspective and separately from a humanistic perspective will provide richer insight into ultimately what they’ll then explain as what they do as a result.

Beyond our techniques, the recommendations we make should also keep SDM in mind. Specifically, we should be asking ourselves how can education, messaging, and materials help support this important practice? We’d love to hear your thoughts on the role of Shared Decision Making and where you see it fitting into clinical practice and/or market research in the future

By Alex Bonello and Liz George


[1]  Roberts BW. Contextualizing personality psychology. J Pers. 2007 Dec;75(6):1071-81. doi: 10.1111/j.1467-6494.2007.00467.x. PMID: 17995457.

[2] Sweller, J. (2010). Cognitive load theory: Recent theoretical advances. In J. L. Plass, R. Moreno, & R. Brünken (Eds.), Cognitive load theory (pp. 29-47). New York, NY, US: Cambridge University Press.

[3] Campbell, W. K., & Sedikides, C. (1999). Self-threat magnifies the self-serving bias: A meta-analytic integration. Review of general Psychology, 3(1), 23-43.

[4] Wallston, K. A., & Wallston, B. 5. (1981). Health locus of control scales. In H. M. Lefcourt (Ed.), Research with the locus of control construct: Vol. 1. Assessment methods (pp. 189ó243). New York: Academic Press.

[5] Norton, M. I., Mochon, D., & Ariely, D. (2012). The IKEA effect: When labor leads to love. Journal of consumer psychology, 22(3), 453-460.


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