Knowing what the patient wants: a hospital ethnography studying physician culture in shared decision making in the Netherlands

ObjectivesTo study physician culture in relation to shared decision making (SDM) practice.DesignExecution of a hospital ethnography, combined with interviews and a study of clinical guidelines. Ten-week observations by an insider (physician) and an outsider (student medical anthropology) observer. The use of French sociologist Bourdieu’s ’Theory of Practice’ and its description of habitus, field and capital, as a lens for analysing physician culture.SettingThe gynaecological oncology department of a university hospital in the Netherlands. Observations were executed at meetings, as well as individual patient contacts.ParticipantsSix gynaecological oncologists, three registrars and two specialised nurses. Nine of these professionals were also interviewed.Main outcome measuresCommon elements in physician habitus that influence the way SDM is being implemented.ResultsThree main elements of physician habitus were identified. First of all, the ‘emphasis on medical evidence’ in group meetings as well as in patient encounters. Second ’acting as a team’, which confronts the patient with the recommendations of a whole team of professionals. And lastly ‘knowing what the patient wants’, which describes how doctors act on what they think is best for patients instead of checking what patients actually want. Results were viewed in the light of how physicians deal with uncertainty by turning to medical evidence, as well as how the educational system stresses evidence-based medicine. Observations also highlighted the positive attitude doctors actually have towards SDM.ConclusionsCertain features of physician culture hinder the correct implementation of SDM. Medical training and guidelines should put more emphasis on how to elicit patient perspective. Patient preferences should be addressed better in the patient workup, for example by giving them explicit attention first. This eventually could create a physician culture that is more helpful for SDM.

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The impact of patient narratives on medical students’ perceptions of shared decision making: A randomized controlled trial

10.31234/osf.io/f84cq ◽

2020 ◽

Author(s):

Martina Bientzle ◽

Marie Eggeling ◽

Simone Korger ◽

Joachim Kimmerle

Keyword(s):

Decision Making ◽

Medical Students ◽

Shared Decision Making ◽

Medical Training ◽

Controlled Trial ◽

Future Research ◽

Shared Decision ◽

Randomized Controlled ◽

Information Text ◽

The Impact

BACKGROUND: Successful shared decision making (SDM) in clinical practice requires that future clinicians learn to appreciate the value of patient participation as early as in their medical training. Narratives, such as patient testimonials, have been successfully used to support patients’ decision-making process. Previous research suggests that narratives may also be used for increasing clinicians’ empathy and responsiveness in medical consultations. However, so far, no studies have investigated the benefits of narratives for conveying the relevance of SDM to medical students.METHODS: In this randomized controlled experiment, N = 167 medical students were put into a scenario where they prepared for medical consultation with a patient having Parkinson disease. After receiving general information, participants read either a narrative patient testimonial or a fact-based information text. We measured their perceptions of SDM, their control preferences (i.e., their priorities as to who should make the decision), and the time they intended to spend for the consultation.RESULTS: Participants in the narrative patient testimonial condition referred more strongly to the patient as the one who should make decisions than participants who read the information text. Participants who read the patient narrative also considered SDM in situations with more than one treatment option to be more important than participants in the information text condition. There were no group differences regarding their control preferences. Participants who read the patient testimonial indicated that they would schedule more time for the consultation.CONCLUSIONS: These findings show that narratives can potentially be useful for imparting the relevance of SDM and patient-centered values to medical students. We discuss possible causes of this effect and implications for training and future research.

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THU0647-HPR SHARED DECISION MAKING AMONGST RHEUMATOLOGISTS IN TRAINING IN THE NETHERLANDS: WHERE DO WE STAND?

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2020-eular.4142 ◽

2020 ◽

Vol 79 (Suppl 1) ◽

pp. 568.2-568

Author(s):

L. Kranenburg ◽

M. Dankbaar ◽

N. Basoski ◽

W. Van den Broek ◽

J. Hazes

Keyword(s):

Decision Making ◽

The Netherlands ◽

Shared Decision Making ◽

Online Survey ◽

Daily Practice ◽

Clear Understanding ◽

Shared Decision ◽

Professional Activities ◽

Self Evaluation ◽

The Subject

Background:The training curriculum for rheumatologists in training in the Netherlands describes competences and entrusted professional activities (EPA) to monitor the progress in learning. However, this training program does not discuss training of Shared Decision Making. As the basis for shared care and patient participation is made during these years, the question arises how rheumatologist in training think about Shared Decision Making and how they use this in daily practice.Objectives:Inventory of vision, experience and self-evaluation of skills related to Shared Decision Making amongst rheumatologists in training in the Netherlands in order to identify barriers in the implementation of Shared Decision Making in daily practice.Methods:Qualitative data was collected from on online survey amongst rheumatologists in training who were registered in January 2018 by the Dutch Society of Rheumatology.Results:Forty-two rheumatologists in training from various years of training responded (60%). Respondents think that Shared Decision Making is important. A third applies Shared Decision Making on a regular basis in daily practice. Self rating of skills for Shared Decision Making varies from sufficient to good. However, respondents are uncertain about their performance due to a lack of feedback and unclearness of the concept. They indicate that Shared Decision Making is not possible for all patients and find it difficult to assess whether the patient has a clear understanding of the options. Patient’s preferences are discussed only by 33% of the doctors on a regular basis when starting new treatment.Conclusion:Rheumatologists in training agree on the importance of Shared Decision Making, but are uncertain about their performance. Unclearness of the concept is described as a known barrier in literature1,2and is frequently mentioned by respondents. Rheumatologist in training indicate that not all patients are fit for Shared Decision Making. Regarding the limited training on the subject this could also be a misjudgment of patients preferences and lack of experience how to deal with different patient types. There is a clear plea for more training and feedback on the subject. Training should be integrated in the curriculum focusing on how to assess patients preferences and how to apply Shared Decision Making also for patients who indicate to leave decisions up to their doctor.References:[1]van Veenendaal, H.et al.Accelerating implementation of shared decision-making in the Netherlands: An exploratory investigation.Patient Educ Couns101, 2097-2104 (2018).[2]Legare, F., Ratte, S., Gravel, K. & Graham, I. D. Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals’ perceptions.Patient Educ Couns73, 526-535 (2008).Disclosure of Interests:Laura Kranenburg Grant/research support from: Pfizer and UCB for the development of the Reuma App, a tool to support selfmanagement for patients. This is not used for the research related to the submitted abstract., Mary Dankbaar: None declared, Natalja Basoski: None declared, Walter Van den Broek: None declared, Johanna Hazes: None declared

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Evidence-based medicine, shared decision making and the hidden curriculum: a qualitative content analysis

Perspectives on Medical Education ◽

10.1007/s40037-020-00578-0 ◽

2020 ◽

Vol 9 (3) ◽

pp. 173-180

Author(s):

Emélie Braschi ◽

Dawn Stacey ◽

France Légaré ◽

Roland Grad ◽

Douglas Archibald

Keyword(s):

Decision Making ◽

Content Analysis ◽

Shared Decision Making ◽

Evidence Based Medicine ◽

Hidden Curriculum ◽

Qualitative Content Analysis ◽

Evidence Based ◽

Shared Decision ◽

Based Medicine

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Navigating the Decision Space: Shared Medical Decision Making as Distributed Cognition

Qualitative Health Research ◽

10.1177/1049732316665347 ◽

2016 ◽

Vol 27 (7) ◽

pp. 1035-1048 ◽

Cited By ~ 12

Author(s):

Katherine D. Lippa ◽

Markus A. Feufel ◽

F. Eric Robinson ◽

Valerie L. Shalin

Keyword(s):

Decision Making ◽

Shared Decision Making ◽

Distributed Cognition ◽

Medical Decision Making ◽

Medical Training ◽

Adverse Outcomes ◽

Medical Decision ◽

Shared Decision ◽

Access To Information ◽

Decision Space

Despite increasing prominence, little is known about the cognitive processes underlying shared decision making. To investigate these processes, we conceptualize shared decision making as a form of distributed cognition. We introduce a Decision Space Model to identify physical and social influences on decision making. Using field observations and interviews, we demonstrate that patients and physicians in both acute and chronic care consider these influences when identifying the need for a decision, searching for decision parameters, making actionable decisions Based on the distribution of access to information and actions, we then identify four related patterns: physician dominated; physician-defined, patient-made; patient-defined, physician-made; and patient-dominated decisions. Results suggests that (a) decision making is necessarily distributed between physicians and patients, (b) differential access to information and action over time requires participants to transform a distributed task into a shared decision, and (c) adverse outcomes may result from failures to integrate physician and patient reasoning. Our analysis unifies disparate findings in the medical decision-making literature and has implications for improving care and medical training.

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Making shared decision-making (SDM) a reality: protocol of a large-scale long-term SDM implementation programme at a Northern German University Hospital

BMJ Open ◽

10.1136/bmjopen-2020-037575 ◽

2020 ◽

Vol 10 (10) ◽

pp. e037575 ◽

Cited By ~ 1

Author(s):

Marion Danner ◽

Friedemann Geiger ◽

Kai Wehkamp ◽

Jens Ulrich Rueffer ◽

Christine Kuch ◽

...

Keyword(s):

Decision Making ◽

Shared Decision Making ◽

Large Scale ◽

Healthcare Professionals ◽

Medical Center ◽

Ethics Committee ◽

University Hospital ◽

Shared Decision ◽

Programme Implementation ◽

Patient Decision

IntroductionShared decision-making (SDM) is not yet widely used when making decisions in German hospitals. Making SDM a reality is a complex task. It involves training healthcare professionals in SDM communication and enabling patients to actively participate in communication, in addition to providing sound, easy to understand information on treatment alternatives in the form of evidence-based patient decision aids (EbPDAs). This project funded by the German Innovation Fund aims at designing, implementing and evaluating a multicomponent, large-scale and integrative SDM programme—called SHARE TO CARE (S2C)—at all clinical departments of a University Hospital Campus in Northern Germany within a 4-year time period.Methods and analysisS2C tackles the aforementioned components of SDM: (1) training physicians in SDM communication, (2) activating and empowering patients, (3) developing EbPDAs in the most common/relevant diseases and (4) training other healthcare professionals in SDM coaching. S2C is designed together with patients and providers. The physicians’ training programme entails an online and an in situ training module. The decision coach training is based on a similar but less comprehensive approach. The development of online EbPDAs follows the International Patient Decision Aid Standards and includes written, graphical and video-based information. Validated outcomes of SDM implementation are measured in a preintervention and postintervention evaluation design. Process evaluation accompanies programme implementation. Health economic impact of the intervention is investigated using a propensity-score-matched approach based on potentially preference-sensitive hospital decisions.Ethics and disseminationEthics committee review approval has been obtained from Medical Ethics Committee of the Medical Faculty of the Christian-Albrechts-University Kiel. Project information and results will be disseminated at conferences, on project-hosted websites at University Hospital Medical Center Schleswig Holstein and by S2C as well as in peer-reviewed and professional journals.

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What are the links between evidence-based medicine and shared decision-making in training programs for junior doctors? A scoping review protocol

BMJ Open ◽

10.1136/bmjopen-2020-037225 ◽

2020 ◽

Vol 10 (5) ◽

pp. e037225

Author(s):

Mary Simons ◽

Frances Rapport ◽

Yvonne Zurynski ◽

Jeremy Cullis ◽

Andrew Davidson

Keyword(s):

Decision Making ◽

Shared Decision Making ◽

Scoping Review ◽

Evidence Based Medicine ◽

Cochrane Library ◽

Junior Doctors ◽

Evidence Based ◽

Shared Decision ◽

Patient Centred Care ◽

Based Medicine

IntroductionPatient-centred care is pivotal to clinical practice and medical education. The practice of evidence-based medicine (EBM) and shared decision-making (SDM) are complementary aspects of patient-centred care, but they are frequently taught and reported as independent entities. To effectively perform all steps of EBM, clinicians need to include patients in SDM conversations, however, the uptake of this has been slow and inconsistent. A solution may be the incorporation of SDM into EBM training programmes, but such programmes do not routinely include SDM skills development. This scoping review will survey the literature on the kinds of EBM and SDM educational programmes that exist for recently qualified doctors, programmes that incorporate the teaching of both EBM and SDM skills, as well as identifying research gaps in the literature.Methods and analysisLiterature searches will be conducted in the databases Medline, Embase, Scopus and Cochrane Library. Bibliographies of key articles and their citing references will also be hand-searched and assessed for inclusion. Selected grey literature will be included. Papers must be written in English, or provide English abstracts, and date from 1996 to the present day.Two independent reviewers will screen titles and abstracts, check full texts of selected papers for eligibility and extract the data. Any disagreement will be resolved, and consensus reached, if necessary, with the assistance of a third reviewer. Qualitative and quantitative studies that address educational interventions for either EBM, SDM or both will be included. Data extraction tables will present bibliographic information, populations, interventions, context and outcomes. Data will be summarised using tables and figures and a description of findings.Ethics and disseminationThis review will synthesise information from publicly available publications and does not require ethics approval. The results will be disseminated via conference presentations and publications in medical journals.

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SHARED DECISION MAKING IN ONCOLOGY AND PALLIATIVE CARE

The International Journal of Person Centered Medicine ◽

10.5750/ijpcm.v8i4.897 ◽

2020 ◽

Author(s):

Paul A Glare

Keyword(s):

Decision Making ◽

Palliative Care ◽

Shared Decision Making ◽

Cognitive Biases ◽

Treatment Options ◽

Care Plan ◽

Treatment Modalities ◽

Shared Decision ◽

Human Decision ◽

Based Medicine

Background: Cancer raises many questions for people afflicted by it. Do I want to have genetic testing? Will I comply with screening recommendations? If I am diagnosed with it, where will I have treatment? What treatment modalities will I have? Will I go on a clinical trial? Am I willing to bankrupt my family in the process of pursuing treatment? Will I write an advance care plan? Will I accept hospice if I have run out of available treatment options? Most of these questions have more than one correct answer, and the evidence for the superiority of one option over another is either not available or does not allow differentiation. Often the best choice between two or more valid approaches depends on how individuals value their respective risks and benefits; “preference-based medicine” may be more important than “evidence-based medicine.” There are various models for eliciting preferences, but applying them can raise a number of challenges. Objectives: To present the concepts, the value, the strategies, the quandaries, and the potential pitfalls of Shared Decision Making in Oncology and Palliative Care. Method: Narrative review. Results: Some challenges to practicing preference-based medicine in oncology and palliative care include: some patients don’t want to participate in shared decision making (SDM); the whole situation needs to be addressed, not just part of it; but are some topics out of bounds? Cognitive biases apply as much in SDM as any other human decision making, affecting the choice; how numerically equivalent data are framed can also affect the outcome; conducting SDM is also important at the end of life. Conclusions: By being aware of the potential pitfalls with SDM, clinicians are more able to facilitate the discussion so that the patients’ choices truly reflect their informed preferences, at a time when stakes and emotions are high.

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