Code	Description	Example
Establishing a problem
Reason for consultation established	Doctor explicitly outlines aims of consultation	Now I understand that Dr XXX has sent you to me to discuss whether chemotherapy would be useful for you
History reviewed	Doctor goes over recent medical history relevant to the current cancer to ensure mutual understanding	Now my understanding is that you were diagnosed with an early stage breast cancer, and on surgery, 3 nodes were found to have cancer in them. Is that right?
Social circumstances reviewed	Doctor establishes the patient’s social and employment circumstances	And are you working? Are you married?
Doctor–patient relationship
Interruptions	Consultation is interrupted by one or more phone calls or the doctor being called out of the room
Rapport Building	Doctor attempts to build rapport through social exchange or empathic responses	That must have been quite a shock.This may feel overwhelming right now, but I will give you some booklets to take home
Research evidence
Evidence presented	Doctor presents evidence underlying treatment options presented	We know from studying 1000s of women like you, that this treatment will reduce the chances of the cancer coming back from 30% to about 20%
Quality of research discussed	Doctor comments on the strength of evidence	Only one fairly small study has shown [drug x] is better than the standard treatment
Research relevant to the patient	Doctor individualizes the evidence to the patient’s circumstances	The study showed that women who were over 70, like you, had a much better chance of avoiding recurrence if they had chemotherapy, than if they didn’t
Physician appraisal of the data	Doctor provides a clear recommendation based on his or her own appraisal of the data	In my view, there is a clear benefit to having the chemotherapy
Patient perspective
Patient asked how much information they wanted	Doctor offers a range of information and determines patient preferences	Now some people like a lot of detail, and others are big picture people. What sort of person are you?
Patient asked for decision making preference	Doctor asks how involved patient wants to be in the decision	Would you like to have a think about what I have said and let me know what you decide, or would you rather I choose the treatment for you, based on what I know about you? Or we could decide together now what we both think is the best course
Physician ensured patient understanding	Doctor checks that the patient has understood what was discussed.	So did that all make sense? How do you see the options in front of us?
Patient views enquired upon	Doctor checks what decisional leaning the patient has	So having heard about the pros and cons of chemo, what are you thinking?
Decision making
Treatment option presented	Doctor explicitly states that there is at least two options (including no treatment)	So the surgery has removed all visible cancer. We could stop there, or you could consider a further treatment to reduce the risk of the cancer coming back
Multiple options presented	Doctor presents multiple options if appropriate	We could do nothing, or you could try tamoxifen alone, or you could have chemotherapy followed by tamoxifen. There are a few options here
Treatment process described	Doctor clearly outlines the procedures involved with having treatment	If you decide to have chemotherapy, you would be coming in here once every three weeks just for the day; we would…
Side effects discussed	Doctor clearly outlines the side effects of each treatment option	There are some downsides of chemo which you may have heard of. They vary depending on the specific drugs used. With this drug, you are likely to have fairly complete hair loss, …
Possible benefits discussed	Doctor clearly states likely benefits of each option	If you decide not to have chemotherapy, you avoid the side effects from a toxic therapy that you may not have needed anyway. However, we have no way of knowing whether all the cancer has gone already. So people have chemotherapy to reduce the chances of the cancer coming back, given that uncertainty
Patient values in decision considered	Doctor clearly states that the patient’s values play an important role in the optimal treatment choice	So what matters to you is the important thing here–whether you want to feel you have done everything possible to avoid the cancer coming back, or feel that the side effects of chemo are just not worth that
Time issues
Option given to defer treatment decision	Doctor clarifies that there is time to think about the options before making a decision	There’s time for you to go home and talk this over with your husband before making a decision. It won’t make any difference when we start the chemotherapy, as long as it is within about 4 weeks of the surgery–so don’t feel rushed