2.3.2 current way of decision-making and providing information. 13
2.3.3 barriers and facilitators for shared decision-making. 14
2.3.4 current use of and attitude towards decision aids 14
2.4 Analysis of Data 15
3 Results 15
3.1 Response Rates 15
3.2 Respondents’ Characteristics and Background Variables 15
3.3 Current extend of providing information 16
3.4 Current way of decision-making 17
3.5 Barriers and facilitators for shared decision making 18
3.6 Current use decision aids 20
3.7 Attitude towards decision aids 20
3.8 Influence of physiatrists’ characteristics and work settings on physiatrist attitude towards shared decision-making 21
4 Discussion 23
4.1 Study Findings 23
4.2 Limitations and Recommendations 26
4.3 Conclusions 27
5 Acknowledgements 28
6 References 28
Appendix: Final version of the questionnaire 31
During a consultation in the clinical setting, decisions regarding plans for treatment often need to be made. A model for reaching such a decision gaining more ground is the shared decision-making model. In this model both physician and patient are actively involved in the decision-making process. This model stands central in the present study. Shared decision-making is just one of several types of treatment decision-making models that can be found in the clinical setting. These types differ from one another in the roles both the physician and the patient play. To gain a better understanding where the shared decision-model fits in, other models will be briefly reviewed.
The paternalistic model is the more traditional model for the medical encounter. The physician is seen as the expert and dominates the consultation, using his skills and expertise to recommend a treatment. This places the patient in a passive, dependent role, while the physician functions as a guardian of the patient’s best interest. As Charles, Gafni, and Whelan (1997, p.386) point out, in the paternalistic model “technical knowledge resides in one party to the interaction- the physician, while preferences reside in the other- the patient”. When one views the degree of patient participation in the decision-making process as a continuous spectrum, the paternalistic model can be placed at one end. On the other side of the spectrum, one finds the informed decision-making model. In this latter model, treatment decision control is seen to be vested in the patient. The role of the physician is to provide all the information about the possible options to the patient. The thereby ‘informed’ patient is considered capable of making the treatment decision on her own (Charles et al., 1997).
A decision-making model that can be placed between the paternalistic model and the informed decision making model is the model of shared decision-making. This model is characterized by a sharing of information by both physician and patient and discussion about the preferred plans for treatment (Trevena, & Barratt, 2002). During the consultation the physician provides information on the medical situation and the patient brings forward her values and preferences. Contrary to the paternalistic model, the physician provides available information about all treatment options. The fact that the responsibility for the decision-making process is shared between the physician and the patient distinguish it from the informed decision-making model.
In previous studies the term shared decision-making is used in different ways. For the present research the definition of Silvia, Ozanne, and Sepucha (2007, p.46) is used: “Shared decision-making is the collaborative decision-making process in which the doctor and patient share information and values in order to make an informed choice that is based on the patient’s value.” Despite apparent differences in definitions, some elements are present in most of them. Elements that most often occur in definitions of shared decision-making are ‘patient values/preferences’, ‘options’ and ‘partnership’ (Makoul, & Clayman, 2006). Charles et al. (1997) identified four criteria for classifying a decision-making interaction as shared. These criteria are:
As shared decision is becoming more familiar, more research has focused on the effects of this way of decision-making in the clinical setting. Beneficial outcomes are found in literature such as enhanced reported satisfaction in patients (Ford, Schofield, & Hope, 2003; Edwards, Elwyn, Woods, Atwell, Prior, & Houston, 2005; Edwards, & Elwyn, 2006) and improved adherence to treatment plans (Speedling, & Rose, 1985; Ford et al., 2003; Edwards et al., 2005). Other desirable patient outcomes reported in literature are enhanced confidence in the decision (Edwards, & Elwyn, 2006; Ford et al. 2003), greater understanding of the treatment decision (Edwards, & Elwyn, 2006) and better psychological adjustment to illness (Ford et al.). There is even evidence suggesting symptom resolution (Ford et al. 2003; Stewart, Brown, Donner, McWhinney, Oates, Weston, & Jordan, 2002) and better treatment results (Trevena, & Barratt, 2003; Stewart et al., 2002).
Besides these benefits, there are also drawbacks reported in literature regarding shared decision-making. A study by Edwards, and Elwyn (2006, p.307) points out, that “unsatisfactory interaction can arise when the actual decisional responsibility does not align with the preferences of the patient at that stage of a consultation”. Another concern expressed in this article is that the increasing patient involvement in decision-making might lead to greater demand for unnecessary, costly or harmful procedures which could undermine the equitable allocation of healthcare resources. Elwyn, Edward, Kinnersley, and Grol (2000) indicate that anxiety can occur in the face of uncertainty about the best course of action. Also, revealing the uncertainties inherent in medical care could be harmful and providing information about the potential risks and benefits of all treatment options might not be feasible, as mentioned by Coulter (1997). Overall though, the patient centeredness that stands central in de shared decision-making approach is widely advocated.
The shared decision-making approach becomes especially relevant when treatment decisions need to be made in a situation of equipoise. Such a situation arises when evidence about the effectiveness of the treatments is not available, or when the available evidence shows no clear best option. Aspects of the different treatments other than proved effectiveness then become of greater value to consider in the decision-making process. Discussing the patient preferences regarding such aspects is an important feature of shared decision-making, as can readily be seen in the definition mentioned above. The patient values then make a decision ‘the right one’.
In the rehabilitation healthcare shared decision-making may be well at place, since situations of equipoise are common. For example, people suffering from a cerebrovascular accident (CVA) may be confronted with a deviant position of the foot and ankle, also known as equinovarus deformity. For this condition, several treatment options are available (e.g. surgical, technologic, pharmaceutical and orthotic treatments). Yet the decision for treatment has to be made in the absence of convincing evidence (Van Til, Renzenbrink, Dolan, & IJzerman, 2008). Patient values on comfort, daily impact, and cosmetics for example, then become of greater value in the decision-making process. Besides greater occurrence of this situation of equipoise, situations encountered in the rehabilitation healthcare are often not acute. Having more time to spend on reaching a treatment decision could mean more room for the implementation of a shared decision-making interaction before making a decision.
As part of an earlier study (Pouw, 2007), some physiatrists from a Dutch rehabilitation centre were asked about their use of shared decision-making using a questionnaire with additional interviews. The results indicated that these physiatrists preferred to share the decision-making process with their patients. This study aimed to provide more insight in the role of shared decision-making in rehabilitation healthcare, by approaching more physiatrists. Four research questions were formulated. The first question asks how much information physiatrists share with their patients and how physiatrists currently make treatment decisions with their patients. Do they already employ a shared decision-making approach or are they more likely to use a more paternalistic approach?
Research on the current use of shared decision-making or a more patient centered approach in general in healthcare settings shows different results depending on the method used. A study by Charles, Gafni, & Whelan (2004) showed that oncologists and surgeons expressed high levels of comfort with the shared decision-making approach. The majority of these physicians also reported employing this approach usually. On the other hand, studies of the doctor-patient interaction have shown that patients are usually not included in the therapeutic decisions in a way that could be called shared decision-making. Braddock, Edwards, Hasenberg, Laidley & Levinson (1992) reported, after analyzing over 1000 doctor-patient consultations, that only nine percent of their audio-taped discussions met all criteria for shared decision-making.
Whether a shared decision model is actually used during a consultation depends on several factors. Some of these factors can ease the implementation of the model and some can be seen as barriers to implementation. Researchers have tried to identify these factors. A systematic review done by Gravel, Légaré, and Graham (2006) showed that time constraints, lack of applicability due to patient characteristics and lack of applicability due to the clinical situation are barriers most often reported on. Three facilitators for the shared decision-making approach often found in literature are provider motivation, positive impact on the clinical process and positive impact on patient outcomes. To see whether shared decision-making is applicable in rehabilitation healthcare, a second research question was formulated, asking how physiatrists view the applicability of shared decision-making in the rehabilitation healthcare and which barriers and facilitators they encounter.
This study also tried to find out whether the attitude of physiatrists towards shared decision-making is influenced by characteristics of the work setting or physician’s characteristics, making up the third research question. Considering the work setting, physiatrists might have a more negative attitude towards shared decision-making when they see many patients each week, since dealing with many patients may leave little room for an elaborate decision-making technique. This may also be the case when the duration of a consultation is limited. Perhaps physiatrists working in different healthcare centres show differences in their opinion on shared decision-making. No great differences in appropriateness of the model for a hospital setting and a rehabilitation centre are expected at forehand however.
Research by Edwards, and Elwyn (2004) showed that female participants showed a more positive attitude change towards using a patient centred approach after training in shared decision-making skills than did male participants. A meta-analytic review on physician gender effects in medical communication by Roter, Hall, & Aoki (2002) revealed that female physicians engage in significantly more active partnership behaviours. No gender differences were evident in the amount of biomedical information giving, according to this review. Based on these findings it was expected to find female physiatrists to hold more positive attitudes towards patient centred approaches.
As a patient centred approach has gained more ground in recent years, the physiatrist’s age and years in practice may also influence his or her view on shared decision-making. Younger physiatrists and those who graduated more recently may therefore be more familiar and comfortable with the shared decision-making approach. It was also expected that physiatrists working primarily with patients who suffered a CVA or traumatic brain injury would hold a more negative attitude towards shared decision-making or models with great patient involvement in general, since cognitive impairments may limit patient’s ability to make decisions.