In today’s fast-paced environment, family physicians can realize the ideal of shared decision making by applying it when it matters most.
Fam Pract Manag. 2001 Sep;8(8):50-51.
In an era of growing health care consumerism, patients have become important partners in making medical decisions. “Participatory decision making,” in which physicians encourage patients to be involved in treatment decisions and to take responsibility for their care, appears to have a number of important benefits. Studies have shown that increased patient involvement in the medical visit1 and greater patient control2 are positively related to patient health status. Furthermore, a physician style that elicits patient opinions has been associated with greater levels of patient satisfaction.3
Patient participation in decision-making is a widely held ethical ideal as well. In many ways, family practice is uniquely positioned to help encourage this ideal, given the specialty’s broad clinical range and its focus on relationships. At the same time, however, family practice is filled with seemingly endless demands on clinicians and staff. Can the ideal of participatory decision making be realized in the fast-paced, high-pressure environment that characterizes many family practices today?
ILLUMINATING THE ‘BLACK BOX’ OF PRIMARY CARE
This article continues our series offering practical lessons from the Direct Observation of Primary Care (DOPC) Study, which was funded by the National Institutes of Health and conducted by the Center for Research in Family Practice and Primary Care, with support from the AAFP. The study demonstrates the complexities of the patient visit, the demands of real-world practice and the value of primary care, issues that policymakers, the public and even clinicians have not fully understood. Researchers used a multi-method approach, including direct observation, to study 4,454 patient visits to 138 family physicians in 84 practice sites.
To better understand participatory decision making, we analyzed data from the Direct Observation of Primary Care (DOPC) Study, which examined 4,454 patient visits to 138 family physicians in Northeast Ohio. Direct observation was used to identify visits during which the family physician made comments or posed questions that facilitated and encouraged patient participation in the decision-making process.4 This included open-ended questions (such as “What do you think?” or “How does that sound to you?”) as well as comments that invited patients to discuss their values and beliefs around their treatment and diagnosis plans (such as “Tell me what concerns you have about this treatment plan”).
Family physicians demonstrated great variability in the rates at which they facilitated and encouraged patient involvement in medical decision making. Some physicians were never observed to use comments and questions to encourage participatory decision making, while others used these techniques in more than three-quarters of their patient visits. On average, family physicians encouraged patient decision making in 25 percent of observed visits.
The study found that family physicians selectively focused their encouragement of participatory decision making on visits with patients who demonstrated the greatest medical needs. This included visits with chronically ill patients, patients requiring referrals and patients needing treatment plans and health education. Because visits in which family physicians encouraged patient decision making were, on average, more than 3 minutes longer than other visits, this focus on patients of greatest need represents an efficient use of time. Furthermore, the study found equal rates of patient satisfaction in visits at which participatory decision making was encouraged and those at which it was not. This suggests that focused encouragement of participatory decision making meets the expectations of both chronically ill and acutely ill patients.
Encouraging patients’ participation in medical decision making can help them become more active partners in their medical care; however, our study results show wide variability in family physicians’ use of questions and comments that invite participatory decision making. These results challenge family physicians to reflect on the decision-making style they use in the clinical setting and to strive to involve patients in the process when it matters most. Indeed, by focusing their encouragement of participatory decision making on patients with the greatest medical needs and on visits with complex, long-term decisions, family physicians can help meet the expectations of patients, balance the competing demands of practice, and translate an important ethical ideal into the realities of daily practice.
Robin Gotler is project coordinator in the Family Medicine Research Division of Case Western Reserve University/University Hospitals of Cleveland (CWRU/UHC). Dr. Kikano is an associate professor and acting chairman of family medicine at CWRU/UHC. Dr. Stange is a professor of family medicine, epidemiology and biostatistics, oncology and sociology at CWRU/UHC. He is also director of the Center for Research in Family Practice and Primary Care, one of three family practice research centers funded by the AAFP. Conflicts of interest: none reported.
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1. Greenfield S, Kaplan S, Ware JE. Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med. 1985;102(4):520-528.
2. Kaplan SH, Greenfield S, Ware JE, et al. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care. 1989;27(3):S110-127.
3. Stewart MA. What is a successful doctor-patient interview? A study of interactions and outcomes. Soc Sci Med. 1984;19(2):167-175.
4. Gotler RS, Flocke SA, Goodwin MA, Zyzanski SJ, Murray TH, Stange KC. Facilitating participatory decision making: what happens in real-world community practice? Med Care. 2000;38(12):1200-1209.
Copyright © 2001 by the American Academy of Family Physicians.
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