Objective: Traditional perspectives on shared decision-making (SDM) focus attention on the point in a clinical encounter where discussion of a treatment decision begins. We argue that SDM is shaped not only by initiation of a treatment decision, but also by the entire clinical encounter, and, even more broadly, by the nature of the patient-provider relationship.Method: The Four Habits Approach to Effective Clinical Communication, a validated and widely used framework for patient-provider communication, was used to understand how SDM is integrally tied to the entire clinical encounter, as well as to the broader patient-provider relationship. Results: The Four Habits consists of four categories of behaviors: (1) invest in the beginning; (2) elicit the patient's perspective; (3) demonstrate empathy; and (4) invest in the end. We argue that the behaviors included in all four of these categories work together to create and maintain an environment conducive to SDM. Conclusion: SDM cannot be understood in isolation, and future SDM research should reflect the influence that the broader communicative and relational contexts have on decisions. Practice implications: SDM training might be more effective if training focused on the broader context of communication and relationships, such as those specified by the Four Habits framework.
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