Doctor–patient communication about drugs: the evidence for shared decision making
Introduction
The traditional paternalistic model of medical decision-making, in which doctors make decisions on behalf of their patients, has increasingly come to be seen as outdated (Royal Pharmaceutical Society of Great Britain, 1997). In its place, the role of the patient in the consultation has been emphasised, notably through increasing interest in ‘patient-centred’ strategies (Stewart et al., 1995). Patient-centred medicine stresses the importance of understanding patients' experiences of their illness and any relevant social and psychological factors. It involves doctors employing active listening skills in order to encourage patients to express their agendas, attempting to understand patients' points of view and expectations, and working with patients to find common ground regarding management.
Shared decision making has a number of similarities with patient-centred medicine. However, the concept of shared decision making also includes patients' active involvement in the treatment decision (Katon et al., 1981, Charles et al., 1997, Coulter, 1997). A number of models of shared decision making have been proposed. In this paper we focus on the model outlined by Charles et al. (1997), who argued that shared decision making is only possible if the following four key characteristics are evident. These are that (1) both the patient and the doctor are involved in the decision-making process, (2) both parties share information, (3) both parties take steps to build a consensus about the preferred treatment and (4) an agreement is reached on the treatment to implement.
Charles et al. (1997) argued that these four characteristics are necessary but not sufficient criteria for classifying an interaction as shared decision making. They, along with Coulter (1997), noted that the commitment of both parties to engage in the decision-making process is crucial, although the extent of involvement may vary. Not all patients will want to take control of their medical care, but it is still important that their concerns, desires and values are incorporated into decisions about their care (Guadagnoli and Ward, 1998).
In their discussion, Charles et al. (1997) noted the difficulty of measuring participation in the consultation. They discussed participation in terms of the other three characteristics they believed to be necessary for shared decision making: sharing information, building a consensus and reaching an agreement on the treatment to implement. Participation is not presented as one part of a stepwise approach to shared decision making, but rather as a characteristic that is necessary throughout. They believe the following to be necessary for participation to occur in the consultation. Firstly, the physician must establish an atmosphere in which the patient feels that their views about various treatment options are valued and needed. Secondly, patients' preferences must be elicited so that any treatment options discussed are compatible with patients' lifestyles and values. Thirdly, technical information must be transferred to the patient about options, risks and probable benefits in as unbiased, clear and simple a way as possible. Fourthly, physician participation also includes helping the patient conceptualise the processes of weighing risks and benefits and asking patients questions in order to ensure that the assumptions underlying their treatment preferences are based on fact and not misconception. Fifthly, shared decision-making involves the physician sharing treatment recommendation with the patient and/or affirming the patient's treatment preferences. For patients, shared decision making means a willingness to engage in the decision making process and take responsibility for disclosing preferences, asking questions, weighing and evaluating treatment alternatives and formulating a treatment preference. These ideas have more recently been characterised as “information exchange”, “deliberation about treatment options” and “deciding on the treatment to implement” (Charles et al., 1999, p. 654).
Prescribing decisions are of particular interest when considering communication in the consultation. Studies in a range of countries indicate that most consultations involve a prescription being written (Webb and Lloyd, 1994 (Britain); Britten and Ukoumunne, 1997 (Britain); Cockburn and Pitt, 1997 (Australia); Himmel et al., 1997 (Germany)). Makoul et al. (1995) suggested that whether and how to use medicines are among the most common and important decisions in which patients can participate. They also argued that prescribing requires competence in reaching an understanding with the patient about the nature of the problem, the likely causes and consequences, and the benefits and risks of the proposed treatment. Others point to the importance of exploring both patients' preferences and orientation towards medicines (Britten, 1994), and the different agendas within the prescribing process (Cribb and Barber, 1997).
Doctors and patients both have knowledge that is relevant for the consultation. Doctors have technical knowledge about possible solutions to medical problems. Patients have, through experience, immersion in their culture and past discussion, ideas about what is happening to them (Tuckett et al., 1985). They also have preferences which encompass a range of issues such as beliefs in the necessity or otherwise for a prescription and the extent and type of side effects they would be willing to tolerate. Both parties need to participate in the consultation to discuss their respective beliefs.
This paper presents data from 62 British consultations, supplemented by data from interviews conducted with both general practitioners and patients. The aims of the study were to conduct an in-depth exploration of the expectations and perceptions of patients prior to consulting a general practitioner (GP) and to relate these to the behaviour of GPs and patients in the consultation, and to subsequent medicine taking. We also collected data on doctors' and patients' views about what happened in the consultation.
For the purposes of this paper, we focus on patients' and general practitioners' participation in the consultation in terms of sharing information about, and views of, medicines. In this way we examine the first two of the four characteristics of shared decision making identified by Charles et al. (1997). We contend that if these are not met then this precludes reaching a consensus about preferred treatment and an agreement on the treatment to implement; the two other characteristics of shared decision making identified by Charles et al.
Section snippets
Methods
The research was conducted in the West Midlands and the Southeast of England between September 1996 and January 1998. The final dataset contains data provided by 20 doctors and 62 patients. Ethical approval was obtained from 11 local research ethics committees.
Results
Prescriptions were issued in 41 of the 62 consultations (66%). The majority (83%, 34/41) of prescriptions issued were either ‘new’ prescriptions or changes to the doses of existing medicines. This paper draws mainly upon these 34 prescriptions. The remaining seven (17%) prescriptions were repeat prescriptions where no changes were made. In eight cases people received both a repeat prescription and a new medicine. Although 21 people (34%) left the consultation with no prescription, the
Discussion
Discussions about shared decision making currently tend to be based on data from North America, and, due to differences in the health care system, are not necessarily comparable with evidence based on British primary care consultations (Coulter, 1997). We used a model developed in Canada (Charles et al., 1997) to examine data collected from a study of 62 general practice consultations in England.
We focused on the extent to which basic information about medicines was shared. In 19 of the 34
Conclusions
Despite the emphasis in medical education on communication skills, the first two key characteristics which Charles et al. (1997) believe to be necessary for shared decision making, which are the participation of patients and GPs in sharing information about medicines and views of medicines, were not generally detected in our data. Moreover, even when information was shared, patients' beliefs in particular were not generally taken seriously, a finding that supports the work published by Tuckett
Acknowledgements
This project was funded as part of the Department of Health Prescribing Research Initiative. We would like to thank all the patients, reception staff and GPs who took part in this study. We wish to acknowledge Roisin Pill and Elizabeth Murphy for their helpful and constructive suggestions about the development of this research. We also wish to acknowledge the constructive comments of two anonymous referees. A version of this paper was presented at the BSA Medical Sociology Conference, September
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