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. 2000 Nov;50(460):892–899.

Shared decision making and the concept of equipoise: the competences of involving patients in healthcare choices.

G Elwyn 1, A Edwards 1, P Kinnersley 1, R Grol 1
PMCID: PMC1313854  PMID: 11141876

Abstract

BACKGROUND: Involving patients in healthcare decisions makes a potentially significant and enduring difference to healthcare outcomes. One difficulty (among many) is that the 'involvement' of patients in decisions has been left undefined. It is usually conceptualised as 'patient centredness', which is a broad and variably interpreted concept that is difficult to assess using current tools. This paper attempts to gauge general practitioners' (GPs') attitudes to patient involvement in decision making and their views about the contextual factors, competences, and stages required to achieve shared decisions within consultations. AIM: To explore and understand what constitutes the appropriate involvement of patients in decision making within consultations, to consider previous theory in this field, and to propose a set of competences (skills) and steps that would enable clinical practitioners (generalists) to undertake 'shared decision making' in their clinical environment. METHOD: Qualitative study using focus group interviews of key informants. RESULTS: Experienced GPs with educational roles have positive attitudes to the involvement of patients in decisions, provided the process matches the role individuals wish to play. They perceive some clinical problems as being more suited to a cooperative approach to decision making and conceptualised the existence of professional equipoise towards the existence of legitimate treatment options as an important facilitative factor. A sequence of skills was proposed as follows: 1) implicit or explicit involvement of patients in the decision-making process; 2) explore ideas, fears, and expectations of the problem and possible treatments; 3) portrayal of equipoise and options; 4) identify preferred data format and provide tailor-made information; 5) checking process: understanding of information and reactions (e.g. ideas, fears, and expectations of possible options); 6) acceptance of process and decision making role preference; 7) make, discuss or defer decisions; 8) arrange follow-up. CONCLUSIONS: These clinicians viewed involvement as an implicit ethos that should permeate medical practice, provided that clinicians respect and remain alert to patients' individual preferred roles in decision making. The interpersonal skills and the information requirements needed to successfully share decisions are major challenges to the clinical consultation process in medical practice. The benefits of patient involvement and the skills required to achieve this approach need to be given much higher priority at all levels: at policy, education, and within further professional development strategies.

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Selected References

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  1. Benbassat J., Pilpel D., Tidhar M. Patients' preferences for participation in clinical decision making: a review of published surveys. Behav Med. 1998 Summer;24(2):81–88. doi: 10.1080/08964289809596384. [DOI] [PubMed] [Google Scholar]
  2. Charles C., Gafni A., Whelan T. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med. 1999 Sep;49(5):651–661. doi: 10.1016/s0277-9536(99)00145-8. [DOI] [PubMed] [Google Scholar]
  3. Charles C., Gafni A., Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med. 1997 Mar;44(5):681–692. doi: 10.1016/s0277-9536(96)00221-3. [DOI] [PubMed] [Google Scholar]
  4. Coulter A., Entwistle V., Gilbert D. Sharing decisions with patients: is the information good enough? BMJ. 1999 Jan 30;318(7179):318–322. doi: 10.1136/bmj.318.7179.318. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Coulter A. Paternalism or partnership? Patients have grown up-and there's no going back. BMJ. 1999 Sep 18;319(7212):719–720. doi: 10.1136/bmj.319.7212.719. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Deber R. B., Kraetschmer N., Irvine J. What role do patients wish to play in treatment decision making? Arch Intern Med. 1996 Jul 8;156(13):1414–1420. [PubMed] [Google Scholar]
  7. Elwyn G., Edwards A., Gwyn R., Grol R. Towards a feasible model for shared decision making: focus group study with general practice registrars. BMJ. 1999 Sep 18;319(7212):753–756. doi: 10.1136/bmj.319.7212.753. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Elwyn G., Edwards A., Kinnersley P. Shared decision-making in primary care: the neglected second half of the consultation. Br J Gen Pract. 1999 Jun;49(443):477–482. [PMC free article] [PubMed] [Google Scholar]
  9. Elwyn Glyn, Gwyn Richard, Edwards Adrian, Grol Richard. Is 'shared decision-making' feasible in consultations for upper respiratory tract infections? Assessing the influence of antibiotic expectations using discourse analysis. Health Expect. 1999 May;2(2):105–117. doi: 10.1046/j.1369-6513.1999.00045.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Guadagnoli E., Ward P. Patient participation in decision-making. Soc Sci Med. 1998 Aug;47(3):329–339. doi: 10.1016/s0277-9536(98)00059-8. [DOI] [PubMed] [Google Scholar]
  11. Kinmonth A. L., Woodcock A., Griffin S., Spiegal N., Campbell M. J. Randomised controlled trial of patient centred care of diabetes in general practice: impact on current wellbeing and future disease risk. The Diabetes Care From Diagnosis Research Team. BMJ. 1998 Oct 31;317(7167):1202–1208. doi: 10.1136/bmj.317.7167.1202. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Mazur D. J., Hickam D. H. Patients' preferences for risk disclosure and role in decision making for invasive medical procedures. J Gen Intern Med. 1997 Feb;12(2):114–117. doi: 10.1046/j.1525-1497.1997.00016.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Mead N., Bower P. Measuring patient-centredness: a comparison of three observation-based instruments. Patient Educ Couns. 2000 Jan;39(1):71–80. doi: 10.1016/s0738-3991(99)00092-0. [DOI] [PubMed] [Google Scholar]
  14. Mead N., Bower P. Patient-centredness: a conceptual framework and review of the empirical literature. Soc Sci Med. 2000 Oct;51(7):1087–1110. doi: 10.1016/s0277-9536(00)00098-8. [DOI] [PubMed] [Google Scholar]
  15. Miller S. M. Monitoring versus blunting styles of coping with cancer influence the information patients want and need about their disease. Implications for cancer screening and management. Cancer. 1995 Jul 15;76(2):167–177. doi: 10.1002/1097-0142(19950715)76:2<167::aid-cncr2820760203>3.0.co;2-k. [DOI] [PubMed] [Google Scholar]
  16. Quill T. E., Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med. 1996 Nov 1;125(9):763–769. doi: 10.7326/0003-4819-125-9-199611010-00010. [DOI] [PubMed] [Google Scholar]
  17. Quill T. E., Cassel C. K. Nonabandonment: a central obligation for physicians. Ann Intern Med. 1995 Mar 1;122(5):368–374. doi: 10.7326/0003-4819-122-5-199503010-00008. [DOI] [PubMed] [Google Scholar]
  18. Redelmeier D. A., Koehler D. J., Liberman V., Tversky A. Probability judgement in medicine: discounting unspecified possibilities. Med Decis Making. 1995 Jul-Sep;15(3):227–230. doi: 10.1177/0272989X9501500305. [DOI] [PubMed] [Google Scholar]
  19. Richards T. Partnership with patients. BMJ. 1998 Jan 10;316(7125):85–86. doi: 10.1136/bmj.316.7125.85. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Savage R., Armstrong D. Effect of a general practitioner's consulting style on patients' satisfaction: a controlled study. BMJ. 1990 Oct 27;301(6758):968–970. doi: 10.1136/bmj.301.6758.968. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Towle A., Godolphin W. Framework for teaching and learning informed shared decision making. BMJ. 1999 Sep 18;319(7212):766–771. doi: 10.1136/bmj.319.7212.766. [DOI] [PMC free article] [PubMed] [Google Scholar]

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