Observing decision-making in the general practice consultation: who makes which decisions?

OBJECTIVE: To investigate opportunities for, and types of decision making in the general practice (primary care) consultation, and examine differences in skills of those doctors who are successful at meeting their patients' preferences and those who are less successful. DESIGN: Observation study of doctor-patient consultations in general practice. PARTICIPANTS: Patients attending for routine appointments in 12 general practice surgeries across Oxfordshire. METHODS: A total of 212 doctor-patient consultations were video-recorded. The patients involved completed a questionnaire to elicit their perceptions of how decisions were made. The video-taped recordings were coded with a new instrument, the Evidence Based Patient Choice Instrument (EBPCI), to classify the number and type of decision-making opportunities arising during each consultation. A total of 149 recordings were coded using the Oxbridge Rating Scale to assess the doctors' consultation styles. RESULTS: There was a range of decision-making opportunities in addition to those involving medical treatment. With the exception of 'fitness for work', decisions were generally 'doctor led'. There was only moderate agreement between patient perceptions of their level of involvement in decision making and the objective ratings using the EBPCI. There was wide variation in the ability of doctors to meet their patients' preferences for involvement. CONCLUSIONS: There are many decisions made in primary care consultations, in addition to those about medical treatments, in which patients could be involved to a greater extent than they currently are. Some doctors are significantly better than others at meeting different patients' preferences for their decision-making role. Patients' perceptions of shared decision making appears to be influenced by the doctors' general consultation skills.

What are the ingredients for a successful evidence-based patient choice consultation?: A qualitative study.

The evidence-based patient choice (EBPC) approach is one of a number of newly emerging templates for medical encounters that advocate evidence-informed choice and shared decision-making. These models emphasise respect for patient preferences for involvement in health care decisions and advocate the sharing of good quality evidence-based information. In the medical consultation EBPC involves providing patients with evidence-based information in a way that facilitates their ability to make choices or decisions about their health care. Whereas the key principles of shared decision-making have been conceptualised, so far, no qualitative investigations have been undertaken to establish the key components of an EBPC consultation. Therefore, a series of semi-structured interviews were carried out with key informants to identify the elements and skills required for a successful EBPC consultation to occur. The interviews were conducted with purposively selected UK general practitioners (n=11), hospital doctors (n=10), practice nurses (n=5), academics (n=11) and lay people (n=8). Qualitative analysis of participants' responses was conducted using the constant comparative method. Six main themes emerged from the data, these were research evidence/medical information, the doctor-patient relationship, patient perspectives, decision-making processes, time issues and establishing the patient's problem. All respondents placed importance on doctors and patients being well informed and appraised of the latest available medical evidence. There was a general view that evidence-based information regarding diagnosis and treatment options should be shared with patients during a consultation. However, there were no suggestions as to how this might be achieved in practice. Participants' opinions relating to which model of decision-making should be adopted ranged from favouring an informed choice model, to the view that decision-making should be shared equally. Similarly, there was no clear view on how much guidance a doctor should offer a patient during decision-making concerning the most appropriate treatment option for that patient.

Are patients' decision-making preferences being met?

OBJECTIVE: To investigate the information and decision-making expectations of general practice patients during real life consultations. DESIGN: Post-consultation, quantitative patient preference and enablement questionnaire. SETTING AND PARTICIPANTS: Patients attending for routine appointments in general practice surgeries in Oxfordshire, UK. RESULTS: Thirteen Oxfordshire general practitioners (GPs) volunteered to take part and a total of 171 patients completed and returned the questionnaire. Between a quarter and one-third of patients reported receiving less information than they desired, particularly in relation to the risks and benefits of medical treatments. Patients who preferred the doctor to make decisions for them (35%), were more likely to have their preferences met (64%) compared with patients wishing to share decisions (47%) or make their own (18%) who were less likely to achieve this role (52 and 41%, respectively). However, it could not be demonstrated unequivocally that these differences were statistically significant. In total, 61% of patients perceived that they achieved their preferred decision-making role. No significant differences were found in post-consultation enablement scores between any of the decision preference groups. Patients' assessments indicated that some doctors were more successful at achieving congruence than others. CONCLUSION: The decision-making preferences of general practice patients tend to vary. However, there was a substantial mismatch between the stated preferences of patients for the role they wanted to have in decision-making and what they felt actually took place in their consultation. Therefore, it remains a challenge for doctors to match their consultation style to the decision-making preferences of individual patients.

Barriers to the evidence-based patient choice (EBPC) consultation.

This study was conducted to explore barriers to the implementation of the 'evidence-based patient choice' (EBPC) consultation in medical practice. The theory behind EBPC encompasses the idea that patients should be provided with evidence-based information in a way that facilitates their ability to make choices or decisions about their health care. Semi-structured interviews were conducted with purposively selected general practitioners (GPs) (n=11), hospital doctors (n=10), practice nurses (n=5), academics (n=11) and lay people (n=8). Qualitative analyses of participants' responses were conducted to identify key themes and categories. Lack of medical evidence per se and evidence relevant to individual patients were the most commonly reported barriers to the EBPC consultation. Other barriers included: doctors' attitudes, limited time for doctors to keep up with the evidence and to introduce evidence into the consultation; economic and resource constraints and a lack of technical resources and training to enable doctors to practice this type of approach.