Confusion in and about shared decision making in hospital outpatient encounters

Highlights

• Inadequate shared decision-making may introduce confusion in encounters.

• Physicians sensed inadequacy, but were not able to change communication strategy.

• High participant scores may reflect much effort rather than high quality.

Abstract

Objective

To explore how physician efforts to involve patients in medical decisions align with established core elements of shared decision making (SDM).

Methods

Detailed video analysis of two hospital outpatient encounters, selected because the physicians exhibited much effort to involve the patients in decision making, and because the final decisions were not what the physicians had initially recommended. The analysis was supplied by physician, patient, and observer-rated data from a total of 497 encounters collected during the same original study. The observer-rated data confirmed that these physicians demonstrated above average patient-centred skills in this material.

Results

Behaviours of these two not trained physicians demonstrated confusion about how to perform SDM. Information provided to the patients was imprecise and ambiguous. Insufficient patient involvement did not prompt the physicians to change strategy. Physician and patient reports indicated awareness of suboptimal communication.

Conclusion

Inadequate SDM in hospital encounters may introduce confusion. Quantitative evaluations by patients and observers may reflect much effort rather than process quality.

Practice implications

SDM may be discredited because the medical community has not acquired the necessary skills to perform it, even if it is ethically and legally mandated. Training and supervision should follow regulations and guidelines.

Introduction

Patient-centred medicine [1] has emerged over the last four decades and has gained widespread popularity. Founded on an ethical imperative [2], and consonant with the demands of an increasingly informed population [3], it now represents the dominating principle underlying medical communication curricula in Western societies [4]. One important feature of patient-centred medicine is the involvement of patients in decisions about treatment (shared decision making (SDM)) [5], [6], [7], [8], [9], [10]. Patient-centred medicine and SDM have been embraced politically [11], and in Norway, the Law on patients’ rights mandates these principles [12].

There is no shared definition of SDM [7]. Recently, Elwyn et al. developed a simplified description with a sequential structure; (1) justification of the discussion and team-building, (2) information about alternatives and options, (3) elicitation of patient preferences, and (4) integration to form a shared decision [10], [13]. Clayman et al. have provided a similar scheme for coding SDM with a more detailed structure [14]. This work recognizes the difficulty of coding systems to reflect the complexity of SDM, particularly where several decisions are made and not often in a clear order.

Several authors have discussed dilemmas and challenges in SDM [15], [16], [17]. The sociologist Per Måseide, while acknowledging that the physicians’ power in the asymmetrical relationship to the patient can represent a problem, argues that this power is also necessary and constitutive for adequate medical practice [18]. Furthermore, even under optimal circumstances, patients will be less informed than the physician. Their consequent reliance on the physician's advice and recommendations displays trust in the physician's competence and benevolence [19]. Medical competence includes balancing the powers and risks of treatment. According to Grimen [20], SDM may disrupt this strong connection between power, trust, and risk, creating uncertainty [21]. Such considerations, and the ample evidence showing SDM is not widespread in medical practice, have led critics to question the principle [22].

Patients’ opinions about SDM differ individually, somewhat but not fully explained by factors such as cognitive abilities, health literacy, the complexity of the decision, or frailty [16], [23], [24]. In hospitals, where patients are more seriously ill, they may feel the additional effect of institutional power [24], which also influences staff physicians reducing their freedom to shift from paternalistic to patient-centred medicine [18].

The principle of SDM is regulated by law in Norway and must be implemented in hospitals; however, it is fairly new to medical practice and may challenge the traditional physician-patient relationship. Thus there is a need to study how SDM works in practice. We aimed to explore SDM in real hospital outpatient encounters in order to understand how efforts of patient involvement in medical decisions align with recent descriptions of SDM elements.