Research Paper
Eliciting patient preferences in shared decision-making (SDM): Comparing conversation analysis and SDM measurements

https://doi.org/10.1016/j.pec.2017.05.018Get rights and content

Highlights

  • Formulating hypotheses about patients’ stance can elicit patient preference.

  • The elicited patient preferences are made decision-implicative.

  • They may promote SDM by making decisions contingent on patient preferences.

  • Formulating hypothetical patient preferences may constrain patient choice.

  • Comparing CA and SDM instruments can specify and inform SDM scores.

Abstract

Objective

To explore how physicians bring up patient preferences, and how it aligns with assessments of shared decision-making.

Methods

Qualitative conversation analysis of physicians formulating hypotheses about the patient’s treatment preference was compared with quantitative scores on SDM and ‘patient preferences’ using OPTION(5) and MAPPIN’SDM.

Results

Physicians occasionally formulate hypotheses about patients’ preferences and then present a treatment option on the basis of that (“if you think X + we can do Y”). This practice may promote SDM in that the decisions are treated as contingent on patient preferences. However, the way these hypotheses are formulated, simultaneously constrains the patient’s freedom of choice and exerts a pressure to accept the physician’s recommendation. These opposing effects may in part explain cases where different assessment instruments yield large variations in SDM measures.

Conclusion

Eliciting patient preferences is a complex phenomenon that can be difficult to reduce into an accurate number. Detailed analysis can shed light on how patient preferences are elicited, and its consequences for patient involvement. Comparing CA and SDM measurements can contribute to specifying communicative actions that SDM scores are based on.

Practice implications

Our findings have implications for SDM communication skills training and further development of SDM measurements.

Introduction

Modern medicine is under increasing influence by the public and ethical imperative for shared decision-making (SDM) [1], [2]. In Norway, legislation mandates patients’ “right to participate in choosing between available and medically sound methods of examination and treatment” [3]. However, in practice, SDM has shown to be a complex concept to define, implement, and assess [4], [5], [6], and a recent review concludes that a “major gap in knowledge is whether and how shared decision making works” [7].

Recently, a small body of conversation analytic studies has started to empirically specify how patient involvement and SDM actually play out in authentic encounters; For instance, how patients are offered choice [8], [9], [10] and how patient preferences are dealt with [11], [12]. Our study develops this line of research further, by comparing conversation analysis (CA) with SDM measurements of the same data.

This study identifies and explores a conditional construction, a variant of ‘hypothetical questions’ [13], by which physicians formulate a hypothesis about the patient’s preference and then present a treatment option on the basis of that, taking the following basic form: “if you think X + we/you can do Y”. By preference we refer to patients’ view or stance on the desirability of some particular treatment or examination option. These hypothetical constructions make claims about the recipient’s epistemic domain, and such statements are shown to elicit (dis)confirmation from the recipient in response (so-called ‘statements about B-events’) [14], [15], [16]. Thus, making claims about others’ inner views and thoughts is a well-documented resource for eliciting this, which, as in this case, can be one way of eliciting patients’ treatment pReferences

The aim of this study is: (1) to describe how physicians formulate hypothetical patient preferences and the interactional consequences of this practice for patient involvement in decision-making, (2) compare qualitative analysis of this practice with quantitative assessments of the item ‘patient preferences’ and overall mean scores from two SDM measurements, and (3) discuss how this practice aligns with guidelines and objectives of the SDM component ‘patient preferences’.

Section snippets

Material and selection of data for the present study

147 video-recorded encounters from various non-psychiatric settings in a Norwegian Teaching Hospital, drawn from a larger dataset of 380 encounters [17], have been reviewed by the first two authors in relation with previous studies [18], [19]. The 147 encounters constitute a strategic, inductive sample aimed to include cases from disciplines in which patient participation seemed to be more prevalent. Decision-making sequences in 27 encounters, in which patients were actively involved, were

Conversation analysis of hypothetical formulations about patient preferences

By formulating hypotheses about patients’ preferences, physicians seek to uncover or clarify the recipient’s stance towards a treatment option or some other clinically relevant action. In our data, such hypotheses appear in situations where (1) the physician has presented a treatment recommendation, and (2) the patient has not yet accepted it, the delay in acceptance being potentially interpretable as passive resistance to the recommendation [23]. Below we analyze three types of formulations:

Discussion

This study has explored one way in which physicians elicit patients’ preferences or views towards some treatment: by formulating hypothetical patient stances (“if you think X”), followed by a decision-implicative component (“then Y”). Unfavorable stances are used for giving the patient a choice/possibility to reject the physician’s recommendation, while favorable stances are used as a device for pursuing acceptance to the physician’s recommended option.

In the investigated cases, the treatment

Acknowledgements

The authors thank Bård Fossli Jensen for collecting the videotaped encounters, John Heritage and Charles Antaki for comments on previous versions, and Jürgen Kasper, Simone Kienlin, Maria Kristiansen and Madeleine Latvala for coding the encounters with MAPPIN’SDM and OPTION(5). This work has been funded by the Research Council of Norway (Ref. 204529), and partly supported by the Research Council of Norway through its Centres of Excellence funding scheme, project number 223265.

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