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For much of modern medicine, the question of who should make treatment decisions had a simple answer: the physician. The patient's role was to comply. Over the past century, that assumption has been challenged, refined, and replaced by a series of frameworks that reimagine the clinical encounter. Each framework emerged from a perceived limitation in its predecessor, and each continues to shape how clinicians communicate, deliberate, and decide. The central tension running through this history is whether authority resides with the physician, the patient, or both—and what kind of communication best serves the patient's health and humanity.
For the first two-thirds of the twentieth century, the dominant framework for clinical decision-making was the Paternalistic Model. The physician, armed with specialized knowledge and a duty to act in the patient's best interest, made decisions on the patient's behalf. The patient's role was to assent. This model rested on a deep asymmetry of expertise: the physician understood disease, prognosis, and treatment; the patient did not. Communication was largely one-directional—instruction, reassurance, or persuasion—rather than dialogue. The model's strength was efficiency and decisiveness in acute care, but its weakness was its silence on patient values, preferences, and autonomy. By the 1960s, social movements demanding patient rights, informed consent, and greater transparency in medicine began to erode the paternalistic consensus. Bioethics, consumer advocacy, and landmark legal cases (such as those establishing informed consent as a legal doctrine) created pressure for a new approach.
The first major challenge to paternalism was Informed Decision Making. This framework shifted the physician's role from decision-maker to information-provider. The core logic was that a patient could make a good decision if given sufficient, accurate information about risks, benefits, and alternatives. The physician's duty was to disclose—to transfer clinical knowledge to the patient, who would then deliberate alone and choose. Informed Decision Making responded directly to the paternalistic model's neglect of patient autonomy. It gave patients the right to know and the right to choose. Yet it also placed the entire burden of decision-making on the patient, often without adequate support for deliberation, emotional coping, or value clarification. Communication remained largely informational: a one-way transfer of facts, followed by a patient's solitary choice. This framework improved transparency but did not address the relational and emotional dimensions of clinical encounters. Its limitations became visible as patients reported feeling abandoned to difficult decisions, and as research showed that information alone did not guarantee good decisions or satisfied patients.
Patient-Centered Communication emerged partly as a corrective to the narrow information-transfer model of Informed Decision Making. Drawing on the Biopsychosocial Medicine framework from the broader discipline, it broadened the scope of clinical communication beyond decision-making to include the whole person: their illness experience, psychosocial context, emotions, and preferences. The physician's task was not merely to inform but to understand the patient's narrative, build rapport, elicit concerns, and respond empathetically. This framework transformed medical education, introducing communication skills training, reflective practice, and patient-centered interviewing techniques. Patient-Centered Communication is a broad, meta-level framework: it encompasses the entire clinical encounter, not just the decision moment. It overlaps with Shared Decision Making but is not identical to it. Where Shared Decision Making focuses on a specific collaborative deliberation about treatment options, Patient-Centered Communication addresses the ongoing relationship, the quality of listening, and the creation of a therapeutic alliance. It remains the dominant framework for communication training in medical schools worldwide.
Shared Decision Making (SDM) crystallized in the 1990s as a more focused response to the limitations of both paternalism and Informed Decision Making. Unlike the paternalistic model, SDM rejects unilateral physician authority. Unlike Informed Decision Making, it rejects the idea that information transfer alone is sufficient. Instead, SDM proposes a joint deliberation in which both physician and patient bring distinct forms of expertise: the physician contributes clinical knowledge about options and outcomes; the patient contributes knowledge of their own values, preferences, and life circumstances. Together, they deliberate to reach a decision that is both evidence-informed and value-congruent. SDM is narrower in scope than Patient-Centered Communication—it targets the decision-making moment rather than the entire clinical relationship—but it is more prescriptive about the process: options must be presented, preferences must be elicited, and a collaborative choice must be made. Decision aids (booklets, videos, online tools) were developed to support this process, and measurement tools (such as the Decisional Conflict Scale and the SURE questionnaire) were created to assess decisional quality. SDM has been endorsed by major health systems, professional bodies, and policy organizations as the normative ideal for preference-sensitive decisions. It has not fully replaced Informed Decision Making, which persists in contexts where patient preference is less relevant or where the decision is straightforward. But SDM has largely absorbed the information-transfer logic of Informed Decision Making and added the crucial element of joint deliberation.
Narrative Medicine, developed in the early 2000s, addresses a dimension that earlier frameworks left underdeveloped: the interpretive, meaning-making aspect of illness. While Patient-Centered Communication emphasizes listening to the patient's story, Narrative Medicine goes further by training clinicians in close reading, reflective writing, and narrative analysis. It draws on literary theory and the humanities to equip clinicians with the skills to interpret patients' stories, recognize plot structures, and attend to the emotional and existential dimensions of illness. Narrative Medicine does not compete directly with Shared Decision Making or Patient-Centered Communication; rather, it enriches them by adding a deeper interpretive layer. Its methods—such as parallel charting and narrative-based case discussions—are used in medical humanities curricula and in some clinical settings. Its influence is narrower than that of Patient-Centered Communication or SDM, but it has a durable foothold in medical education and in fields such as palliative care, psychiatry, and primary care, where meaning-making is central.
Today, no single framework dominates. The field is pluralistic, with each framework occupying a distinct niche. Patient-Centered Communication remains the broadest and most widely taught framework, shaping how clinicians approach the whole encounter. Shared Decision Making is the normative ideal for preference-sensitive decisions and is increasingly embedded in policy, quality metrics, and decision aid development. Narrative Medicine continues to influence medical humanities and reflective practice. Informed Decision Making persists in contexts where patient values are less contested or where SDM is impractical. The Paternalistic Model, while no longer normative, survives in emergency settings and in some cultural contexts where physician authority is expected.
The leading frameworks—Patient-Centered Communication and Shared Decision Making—agree on several fundamentals: patients should be active participants, communication should be bidirectional, and decisions should reflect patient values. They disagree, however, on scope and focus. Patient-Centered Communication sees the entire relationship as the unit of analysis; SDM zeroes in on the decision moment. This difference creates practical tensions: should communication training emphasize broad relational skills or specific decision-making protocols? Should quality measurement assess patient-reported experience of the whole encounter or decisional quality for specific choices? Open debates also surround measurement (how to validly assess SDM in routine practice), guideline integration (how to embed SDM into clinical pathways without reducing it to a checklist), and cultural adaptation (how to apply SDM in settings where patient autonomy is not the primary value). Implementation of SDM remains uneven: decision aids are underused, time constraints limit deliberation, and many clinicians still default to information-giving rather than joint deliberation. The field's central question—who decides, and how should they communicate?—remains as urgent as ever, now reframed as a question of how to make shared deliberation practical, equitable, and meaningful across diverse clinical contexts.