The problematic of decision-sharing: deconstructing 'cholesterol' in a clinical encounter.

Shared decision-making is increasingly advocated as a means of interacting with patients but there is also a widely accepted view that many factors will militate against this ideal. While some patients may not wish to take on the responsibility of decision-making, it is also evident that many find it difficult to assimilate probabilities about future events and overestimate the likelihood of some outcomes, especially when terms such as 'stroke', 'bleeding' and 'heart attack' are used in consultation and bring with them emotional connotations and reactions. Under such circumstances, should clinicians portray risks as best they can, in the hope that even a marginally improved understanding will be an improvement on unilateral professional decision-making? Or, conversely, should they 'guide' the decision process, acting in a way that is known as 'professional agency'? Developing some perspectives put forward in recent work by the authors and applying it to a distinct clinical context, this paper will provide (i) a discourse analytic exploration of a single extended example from clinical practice employing aspects of Bakhtin's theory of dialogism, and (ii) a discussion and summary of what we can learn from this analysis in the context of shared decision-making and risk communication.

Is 'shared decision-making' feasible in consultations for upper respiratory tract infections? Assessing the influence of antibiotic expectations using discourse analysis.

OBJECTIVES: To examine the discourse of consultations in which conflict occurs between parents and clinicians about the necessity of antibiotics to treat an upper respiratory tract infection. To appraise the feasibility of shared decision-making in such consultations. DESIGN: A qualitative study using discourse analysis techniques. SETTING: A general practice with 12 500 patients in an urban area of Cardiff, Wales. PARTICIPANTS: Two consultations were purposively selected from a number of audiotaped sessions. The consultations took place during normal clinics in which appointments are booked at 7-minute intervals. The practitioner is known to be interested in involving patients in treatment decisions. METHOD: Discourse analysis was employed to examine the consultation transcripts. This analysis was then compared with the theoretical competencies proposed for 'shared decision-making'. RESULTS: The consultations exhibit less rational strategies than those suggested by the shared decision-making model. Strong parental views are expressed (overtly and covertly) which seem derived from prior experiences of similar illnesses and prescribing behaviours. The clinician responds by emphasizing the 'normality' of upper respiratory tract infections and their recurrence, accompanied by expressions that antibiotic treatment is ineffective in 'viral' illness - the suggested diagnosis. The competencies of 'shared decision-making' are not exhibited. CONCLUSIONS: The current understanding of shared decision-making needs to be developed for those situations where there are dis-agreements due to the strongly held views of the participants. Clinicians have limited strategies in situations where patient treatment preferences are opposed to professional views. Dispelling 'misconceptions' by sharing information and negotiating agreed management plans are recommended. But it seems that communication skills, information content and consultation length have to receive attention if such strategies are to be employed successfully.