The physiatrist’s attitude towards Shared Decision-Making a further analysis among physiatrists on the role of shared decision-making in rehabilitation healthcare



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4Discussion

4.1Study Findings


This study strived to answer four research questions to provide insight in the role shared decision-making currently plays within the rehabilitation healthcare. The first research question asked to what extent physiatrists currently provide information to their patients and which approach they use to make decisions for treatment with their patients. A great deal of information provision by the physiatrist, a prerequisite for shared decision-making, seems to take place during a consultation, although some topics (e.g. extent of disease) are more often discussed than others (e.g. impact of treatment on sexuality). When several treatment options are available, the majority of physiatrists indicated to share these with the patient.

This great amount of information provision is desirable, since this has been linked to higher reported satisfaction by patients in earlier research (Williams, Weinman, & Dale, 1998). A note of caution might be in place though, since this study relied on self-reported measures. This method may have resulted in an overestimation of the degree of information provision. When more objective measures are used, such as analyses of audio- or videotapes, less information sharing is found (e.g. Braddock et al., 2002).

Results show that the majority of physiatrists in this study reported to use the shared decision-making approach as their usual approach to decision-making. The paternalistic approach was the most unpopular approach reported. These results correspond with findings by Charles et al. (2004), who also found that the shared decision-making approach was reported to be most often employed and the paternalistic approach the least by oncologists and surgeons working with breast cancer patients.

A finding from Charles et al. (2004) that was found in the present study as well, is the presence of a considerable discrepancy between physicians’ reported comfort level with the shared decision-making approach and their self-reported use of the approach. This gap rises the question why not all physiatrists reporting high levels of comfort with the shared decision-making approach also use it as their general decision-making approach.

The presence of barriers might explain why this gap exists, which brings us to the second question this study tried to answer was: which barriers and facilitators do physiatrists experience for the process of decision-making in rehabilitation healthcare? The results indicate that physiatrists do perceive barriers to treatment decision-making. Barriers most often identified are ones relating to the healthcare system (e.g. the patient has received conflicting recommendations from various specialists) and to patient characteristics (e.g. the patient has difficulty accepting his/her disease or has misconceptions about the disease or treatment). The time barrier, reported on by many other studies (Gravel, Légaré, & Graham, 2006), was also identified as a barrier by a great portion of the respondents.

More patient participation in decision-making was considered a barrier by only a small portion of the respondents, whereas participation was seen as a facilitator for the decision-making process by the vast majority. Making a decision about treatment was also thought to be eased when the patient has knowledge about the disease and treatment before the consultation and when the patient receives emotional support. Providing information to the patient and their support network before the consultation may therefore be a practical intervention to enhance patient involvement in decision-making.

As mentioned earlier, physiatrists as a group showed the highest levels of comfort with the shared decision-making approach, which is interpreted as holding a positive attitude towards this model. Physiatrists reported positive attitudes towards other models with some form of sharing as well. Does the physiatrist’s attitude depend on personal characteristics as age and years in practice? Or on characteristics of their work setting such as the amount of patients they see? Analyses to answer this third research question showed some significant correlations, some of which might be somewhat counterintuitive.

No significant correlations were found between physiatrists’ age and years in practice and their attitude toward the four decision-making models. The expectation that younger physiatrists would be more likely to engage in shared decision-making is therefore not supported. Significant gender differences only arose in attitude towards the informed decision-making model. Results showed that men reported higher levels of comfort with the informed decision-making model, compared to women. Based on research findings showing greater patient involvement during a consultation with a female physician (Roter, Hall, & Aoki, 2002), the opposite was expected. Perhaps physiatrists are an exception to this general finding, like obstetrics and gynecologists. Of course it should be kept in mind that reporting higher levels of comfort with an approach does not necessarily mean this approach is also practiced more often.

Working with cognitive limited patients also showed significant correlations with the physiatrist’s attitude toward the different decision-making models. As was expected, physiatrists who indicated to work primarily with cognitive limited patients displayed a more positive attitude towards the paternalistic model than the other physiatrists. These physiatrists showed higher levels of comfort with the some sharing approach as well. As the responsibility for the decision in the some sharing example for a large part still lays at the physiatrist, these findings are both in line with the thought that when patients are limited in their ability to make a decision, physiatrists are more likely to take responsibility for it.

A finding unexpected at forehand also appeared. Working with cognitive limited patients showed to be related to holding a more positive attitude towards the informed decision-making approach. Although the mean attitude scores for physiatrists working with cognitive limited patients was lower than that for other physiatrists, this difference did not reach significance.

How can this high preference for both the paternalistic and the informed decision-making approach, both considered to represent the ends of a spectrum, among physiatrists working primarily with CVA patients and patients suffering traumatic brain injury be explained? Perhaps this specific group of patients is actually very divers, showing great differences in the degree to which cognitive limitations are present. In that case, physiatrists might use more diverse ways of decision-making depending on the cognitive level of the patient, rather than use one approach for all patients. If this is so, physiatrists may feel more at ease with each of the approaches, since they are used to employ the different approaches, explaining the more positive attitude towards them.

Although the physiatrists working with cognitive limited patients reported a higher level of comfort with the informed decision-making approach, they reported to employ this approach less often as their usual approach than the other physiatrists. Also, the amount of physiatrists reporting to use the paternalistic approach as their usual approach was higher in the group of physiatrists working with cognitive limited patients, than for the group of physiatrists as a whole. Based on these results, it might be concluded that although they feel comfortable using approaches with more responsibility for the decision residing at the side of the patient, cognitive impairment provides a great barrier and makes physiatrists turn to models with less shared responsibility. Further research on the decision-making process with this specific patient group could provide more insight into the factors explaining these differences.

Another correlation appeared between the amount of patients physiatrists reported to see in a week and their attitude towards the informed decision-making model. Perhaps the great amount of patients involves more patients coming for treatment. The amount of time spent on first consultations, which involve decision-making more often, might be comparable or even greater for these physiatrists. Since this study did not make a distinction between first consultations and follow-ups, no statements about this can be made from this study.

Finally, this study also tried to find out to what extent physiatrists consider decision aids to be useful for the decision-making process. Physiatrists seem to hold a modest positive attitude towards using a decision aid. Many respondents agreed that a decision-aid will cause patients to be more involved in decision-making about the treatment. Most physiatrists reported to use a decision aid regularly or often, which is well in line with the high percentage of physiatrists who reported to use the shared decision-making approach. However, the sort of aid that is used is often ‘just’ a brochure or other form of plain information. The use of more elaborate aids, focusing more on making a decision rather than just providing information about possible options, are not commonly used.




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