Medical Decision Making
Temporal characteristics of decisions in hospital encounters: A threshold for shared decision making? A qualitative study

https://doi.org/10.1016/j.pec.2014.08.005Get rights and content

Highlights

  • Patients are the focus of a large number of decisions in hospital encounters.

  • Decisions are connected to past, present or future medical actions or judgment.

  • Preformed decisions are made prior to the encounter and conveyed as information.

  • Conditional decisions prescribe future actions given a certain course of events.

  • The temporal nature of decisions may serve as a threshold for patient involvement.

Abstract

Objective

To identify and characterize physicians’ statements that contained evidence of clinically relevant decisions in encounters with patients in different hospital settings.

Methods

Qualitative analysis of 50 videotaped encounters from wards, the emergency room (ER) and outpatient clinics in a department of internal medicine at a Norwegian university hospital.

Results

Clinical decisions could be grouped in a temporal order: decisions which had already been made, and were brought into the encounter by the physician (preformed decisions), decisions made in the present (here-and-now decisions), and decisions prescribing future actions given a certain course of events (conditional decisions). Preformed decisions were a hallmark in the ward and conditional decisions a main feature of ER encounters.

Conclusion

Clinical decisions related to a patient–physician encounter spanned a time frame exceeding the duration of the encounter. While a distribution of decisions over time and space fosters sharing and dilution of responsibility between providers, it makes the decision making process hard to access for patients.

Practice implications

In order to plan when and how to involve patients in decisions, physicians need increased awareness of when clinical decisions are made, who usually makes them, and who should make them.

Introduction

Patient-centered care has been promoted for decades [1], [2], [3], [4]. One of its prime requisites is the involvement of patients in medical decisions, a principle built on an ethical imperative [5], [6].

Change has come about slowly [7], [8] and one of the major barriers to patient involvement in decisions is the inherent asymmetry of the patient-physician relationship [9], [10], [11]. Nowhere is this asymmetry greater than in hospitals, where patients are more seriously ill, and physicians are part of a complex, hierarchical, and technically diversified culture. Hospitals are also the cradle of basic physician training and socialization. We hypothesized that scrutiny of patient–physician encounters in hospitals could provide insight into the conditions under which physicians adopt and practice their skills in clinical reasoning and patient communication, hopefully illuminating why shared decision making still has not covered much ground.

Attempts to strengthen patients’ active involvement in medical decisions has been studied and promoted with two conceptually different approaches. Informed decision making (IDM) [12], [13] has evolved within bioethics as an attempt to improve on informed consent. Shared decision making (SDM) [14], [15], [16], [17], [18], developed largely in general practice, aims to support patients in deliberation and determination around decisions entailing equipoise. With almost no exceptions, research on SDM and IDM targets single decisions related to a specified, predetermined topic [19], [20], [21], [22], focusing on difficult decisions with two or more options, where medical evidence provides no clear guidance. However, most clinical encounters deal with several problems and produce several decisions, as illustrated by the work of Braddock et al. They defined a decision as “a verbal statement committing to a particular course of action” [12]. In two separate outpatient studies using this definition, an average of more than three decisions per encounter was found [12], [13], concerning prescriptions, diagnostic tests, referrals and instructions regarding diet and physical activity. While the Braddock definition is broad, it still omits decisions that govern the subsequent courses of action, such as evaluations of findings and tests, and interpretations concerning diagnosis, prognosis and etiology.

Deber has made a distinction between “problem solving” – the physician's search for a single “correct” solution, and “decision making” – the choice of one among several alternatives [23]. Yet medical “problem solving” often involves “decision making” on the path to a conclusion. Contrary to what we might wish, diagnostic conclusions seldom reveal themselves [24]. Most of the time, these processes present options that require decision making and leave room for interpretation because of medical and contextual complexity [25]. In confronting the uncertainties of diagnostics and treatment, the term “decision” tends to be used restrictively for situations where it is possible to calculate the probabilities of outcomes [26], [27], [28], [29]. A more inclusive approach [30] could shed light on the range of decisions that are made in relation to patient–physician encounters. An increased understanding of the full decisional content of clinical encounters may inform a discussion about when and how patients should be involved in decision making.

In health care institutions, many clinical decisions involve input and reflection from several professionals in deliberative processes where patients are not present [31], [32], [33]. While such processes are commonplace in hospitals, the only studies on the nature and frequency of decisions in medical encounters originate from primary care or outpatient clinics [12], [13], [34]. The aim of this inductive study was to identify and characterize all clinically relevant decisions that emerged when physicians interacted with patients in different hospital settings. Halfway through the process, which initially focused on the definition and topical characteristics of decisions, a temporal aspect of clinical decisions emerged. In this paper we describe the details of this temporal dimension and discuss its implications on SDM.

Section snippets

Methods

We used an exploratory qualitative approach to identify and characterize decisions in videotaped hospital encounters.

Results

We found that clinical decisions have a temporal nature and are connected to past, present or future processes of medical action and judgment, respectively. We present the three temporal categories; “here-and-now decisions”, “preformed decisions” and “conditional decisions” through cases 1–3 before presenting the fourth case. The cases represent everyday medicine in the outpatient clinic, the ER and the inpatient ward. Relevant information regarding the video-taped encounters, their context and

Discussion

Our results reflect a broad definition of clinically relevant decisions as they appear to the patient and a temporal categorization based on how decisions are conveyed to patients by physicians. We found that patients are the focus of a large number of clinical decisions and that, almost without exception, these decisions are conveyed as factual information and not as topics for deliberation. From an observer's perspective, physicians seem to deal with diagnostic and therapeutic decisions as if

Conclusion

We identified clinical decisions that could be grouped in a temporal order of here-and-now, preformed or conditional decisions. The characteristics of different clinical settings and thereby availability of information affect decision making by creating context specific patterns and boundaries. Decisions in the ER tended to be conditional, mainly because a lot of information (lab results, tests, imaging) was not yet available, while inpatient ward rounds often involved decisions made prior to

Acknowledgements

The authors thank Bård Fossli Jensen for recording the videos and Håkon Leinan for assistance in figure design. This project is funded by South Eastern Norway Regional Health Authority (grant number 2010003).

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