Commentary
==========

* Richard Thomson
* Aileen Clarke

Recent years have seen increasing emphasis on the patient role in decision making and a move away from the traditional paternalistic medical model.1 In 1980 a Medline search identified 213 papers with the MESH heading of “decision making”. By 2000 this had risen to 2508 papers.

In 1993 a report of a working party on appropriateness of patient care in *QHC* recognised the importance of effective information exchange with patients and the central importance of patient preferences in the choice of appropriate interventions—that is, appropriateness is not purely defined by technical elements of quality such as effectiveness, but also by patient values and perceptions.2 Furthermore, there has been increasing recognition that patient derived outcome measures need to be incorporated alongside, or in place of, traditional clinical or biochemically defined measures, both in research and practice.3–5 Patients' aspirations for the outcomes of their health care may differ from those of their clinicians, and increasing evidence suggests that patients' preferences and those of doctors differ.6

Internationally, the recognition of the changing role of the patient is being reflected in health policy. The UK NHS puts patient and public involvement at the core of recent health policy—for example, recognising the patient as expert in his/her condition, particularly in chronic diseases.7–10 The unsuccessful review of health care initiated by Bill Clinton in the US also put patient and public choice firmly at the centre, albeit in a more market driven model.11 The future of high quality health care can no longer be defined purely, or even substantively, by professional providers: recognising and engaging the patient is an ethical12 and practical necessity, but to do this requires several important developments. Thus, doctors and other clinicians need ready access to evidence-based information in a form that can be clearly communicated to patients.13,14 Furthermore, both patients and clinicians need to be supported in developing new relationships within the changing dynamic of the consultation.15,16

The two preceding papers17,18 come from our two separate research groups and describe the development and piloting of two computerised decision support tools. These projects were separately initiated, with very similar aims, but targeted at two quite different clinical conditions. Each set out to find a mechanism of (1) communicating risks and benefits of treatments clearly to patients who had to make a choice in the face of uncertainty; (2) incorporating patient preferences and/or values into the decision making process; and (3) bringing the evidence base to bear upon such difficult decisions (to the benefit of both the patient and the clinician).

Despite starting out with similar aims and using very similar methods of development, the final products of both teams differ in a number of important respects (table 1). Further development and evaluation of these tools will be undertaken with continuing contact between the two development teams, as there is much we can learn from each other. These are but two examples of the expanding field of decision support tools and decision aids.19 We predict that health care in the 21st century will increasingly depend upon such supports to enhance quality of care and the responsiveness of clinical encounters with patients.

View this table:
[ Table 1 ](http://qualitysafety.bmj.com/content/11/1/38/T1)

 **Table 1 **  
Comparison of the two studies

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