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222 How to include shared decision making in the time needed to treat estimation
  1. Agostina Risso1,
  2. Karin Kopitowski1,
  3. Victor Montori2,
  4. Minna Johansson3,4,
  5. Amanda Niklasson3,4
  1. 1Departamento de Investigación, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
  2. 2The Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, USA
  3. 3Global Center for Sustainable Healthcare
  4. 4General Practice, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden


Growing evidence supports incorporating shared decision-making (SDM) in clinical encounters.1 2. However, the boundless burden of medical tasks poses a challenge as SDM becomes ‘yet another task’ on an endless list,3 and tension exists between evidence-based recommendations and face-to-face time with the patient. For example, general practitioners would have to work 27 hours per day to follow all guidelines that apply to their patients.4

When recommendations are conditional, as advised by the GRADE Working Group, it is customary to recommend their implementation through SDM.5 Furthermore, many strong recommendations also require SDM. Thus, clinical practice guidelines should consider the time that co-creating plans of care with patients take. However, there is no guidance on how this should be done.6

In this symposium, we planned to present and discuss not just the concept of the time needed to implement medical recommendations (known as ‘Time Needed to Treat’ - TNT) but also its impact on primary care, followed by a collaborative work to estimate the TNT for implementing those preventive recommendations, comparing how including and excluding the SDM process affects the time estimation.

In this way, we aim to introduce and emphasize the importance of considering time when formulating clinical practice guidelines and the opportunity costs of such recommendations. In this interactive symposium, we will explore how the audience, knowledgeable in SDM, considers the time it takes to do SDM well at the point of care and what factors should enter into TNT estimates for recommendations, including SDM. We will also explore alternatives for unacceptably high TNT estimates.

This symposium aims to be a space for reflection and action to enhance the effective implementation of SDM in primary care using this innovative approach, the TNT.


  1. Gärtner FR, Portielje JE, Langendam M, et al. BMJ Open. 2019;9(12).

  2. Montori V, Kunneman M. BMJ Evidence-Based Medicine. 2022; Epub ahead of print.

  3. Montori VM, Ruissen MM, Hargraves IG, et al. BMJ Evidence-Based Medicine. 2023;28:213–217.

  4. Porter J, Boyd C, Skandari MR, et al. J Gen Int Med 2022; Epub ahead of print.

  5. Rabi DM, Kunneman M, Montori VM. JAMA. 2020;323(14):1345–1346.

  6. Johansson M, Guyatt G, Montori VM. BMJ 2023;380:e072953.

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