Do consultants do what they say they do? Observational study of the extent to which clinicians involve their patients in the decision-making process

OBJECTIVES: To assess whether consultants do what they say they do in reaching decisions with their patients. DESIGN: Cross-sectional analysis of hospital outpatient encounters, comparing consultants’ self-reported usual decision-making style to their actual observed decision-making behaviour in video-recorded encounters. SETTING: Large secondary care teaching hospital in the Netherlands. PARTICIPANTS: 41 consultants from 18 disciplines and 781 patients. PRIMARY AND SECONDARY OUTCOME MEASURE: With the Control Preference Scale, the self-reported usual decision-making style was assessed (paternalistic, informative or shared decision making). Two independent raters assessed decision-making behaviour for each decision using the Observing Patient Involvement (OPTION)(5) instrument ranging from 0 (no shared decision making (SDM)) to 100 (optimal SDM). RESULTS: Consultants reported their usual decision-making style as informative (n=11), shared (n=16) and paternalistic (n=14). Overall, patient involvement was low, with mean (SD) OPTION(5) scores of 16.8 (17.1). In an unadjusted multilevel analysis, the reported usual decision-making style was not related to the OPTION(5) score (p>0.156). After adjusting for patient, consultant and consultation characteristics, higher OPTION(5) scores were only significantly related to the category of decisions (treatment vs the other categories) and to longer consultation duration (p<0.001). CONCLUSIONS: The limited patient involvement that we observed was not associated with the consultants’ self-reported usual decision-making style. Consultants appear to be unconsciously incompetent in shared decision making. This can hinder the transfer of this crucial communication skill to students and junior doctors

Shared Decision-making in Different Types of Decisions in Medical Specialist Consultations

Backgrounds Research on shared decision-making (SDM) has mainly focused on decisions about treatment (e.g., medication or surgical procedures). Little is known about the decision-making process for the numerous other decisions in consultations. Objectives We assessed to what extent patients are actively involved in different decision types in medical specialist consultations and to what extent this was affected by medical specialist, patient, and consultation characteristics. Design Analysis of video-recorded encounters between medical specialists and patients at a large teaching hospital in the Netherlands. Participants Forty-one medical specialists (28 male) from 18 specialties, and 781 patients. Main Measure Two independent raters classified decisions in the consultations in decision type (main or other) and decision category (diagnostic tests, treatment, follow-up, or other advice) and assessed the decision-making behavior for each decision using the Observing Patient Involvement (OPTION)(5) instrument, ranging from 0 (no SDM) to 100 (optimal SDM). Scheduled and realized consultation duration were recorded. Key Result In the 727 consultations, the mean (SD) OPTION5 score for the main decision was higher (16.8 (17.1)) than that for the other decisions (5.4 (9.0), p < 0.001). The main decision OPTION5 scores for treatment decisions (n = 535, 19.2 (17.3)) were higher than those for decisions about diagnostic tests (n = 108, 14.6 (16.8)) or follow-up (n = 84, 3.8 (8.1), p < 0.001). This difference remained significant in multilevel analyses. Longer consultation duration was the only other factor significantly associated with higher OPTION5 scores (p < 0.001). Conclusion Most of the limited patient involvement was observed in main decisions (versus others) and in treatment decisions (versus diagnostic, follow-up, and advice). SDM was associated with longer consultations. Physicians' SDM training should help clinicians to tailor promotion of patient involvement in different types of decisions. Physicians and policy makers should allow sufficient consultation time to support the application of SDM in clinical practice

Patients' preferred and perceived decision-making roles, and observed patient involvement in videotaped encounters with medical specialists

OBJECTIVE: To assess how patients prefer and perceive medical decision making, which factors are associated with their preferred and perceived decision-making roles, and whether observed involvement reflects patients' perceived role. METHODS: We asked 781 patients visiting a medical specialist from 18 different disciplines to indicate their preferred and perceived decision-making roles. Patient involvement in videotaped consultations was assessed with the OPTION5 instrument. RESULTS: Most patients preferred and perceived decision making as shared (SDM; 58% and 43%, respectively), followed by paternalistic (26% and 38%), and informative (16% and 15%). A large minority (n = 103, 21%) of patients preferring shared or informative decision making (n = 482) experienced paternalistic decision making. Mean (SD) OPTION5 scores were highest in consultations which patients perceived as informative (26.0 (19.7)), followed by shared (19.1 (17.2)) and lowest in paternalistic decision making (11.8 (13.4) p < 0.001). CONCLUSIONS: Most patients want to be involved in decision making. Patients perceive that the physician makes the decision more often than they prefer, and perceive more involvement in the decision than objective assessment by an independent researcher shows. PRACTICE IMPLICATIONS: A clearer understanding of patients' medical decision-making experiences is needed to optimize physician SDM training programmes and patient awareness campaigns

Long-term parental distress after pediatric hematopoietic stem cell transplantation for nonmalignant diseases

Background: Survival rates have continued to increase for pediatric hematopoietic stem cell transplantation (HSCT) for nonmalignant diseases. Despite the crucial role of caregivers in this high-intensity treatment, knowledge about long-term parental impact is lacking. Procedure: This cross-sectional study assessed parental distress and everyday problems in parents of patients 2 years and older after pediatric HSCT for a nonmalignant disease using Distress Thermometer for Parents (DT-P), and compared outcomes to matched Dutch parents of healthy children and Dutch parents of children with a chronic condition (CC). Results: Median follow-up was 5.3 years (interquartile range [IQR]: 2.9–8.6). Underlying diseases were inborn errors of immunity (N = 30), hemoglobinopathies (N = 13), and bone marrow failure (N = 27). Mothers of pediatric HSCT recipients (N = 70) reported comparable overall distress levels to mothers of healthy children, but experienced more distress related to parenting problems, specifically managing their child's emotions, discussing disease consequences, and fostering independence. Fathers of HSCT recipients (N = 45) reported higher overall distress levels and had more emotional distress compared to fathers of healthy children. Conclusions: Overall, parental distress and everyday problems of parents of HSCT recipients are comparable to those of parents of children with CC. However, there is ongoing parental burden, both emotional and in parenting, long-term after HSCT compared to parents of healthy children, and the type of burden differs between mothers and fathers. These results indicate that individualized parental supportive care should not remain restricted to the acute hospitalization phase, but also be actively offered during long-term follow-up after pediatric HSCT.</p

Anticipated adaptation or scale recalibration?

Analysis and support of clinical decision makin

Effect of adaptive abilities on utilities, direct or mediated by mental health?

<p>Abstract</p> <p>Background</p> <p>In cost-utility analyses gain in health can be measured using health state utilities. Health state utilities can be elicited from members of the public or from patients. Utilities given by patients tend to be higher than utilities given by members of the public. This difference is often suggested to be explained by adaptation, but this has not yet been investigated in patients. Here, we investigate if, besides health related quality of life (HRQL), persons' ability to adapt can explain health state utilities. Both the direct effect of persons' adaptive abilities on health state utilities and the indirect effect, where HRQL mediates the effect of ability to adapt, are examined.</p> <p>Methods</p> <p>In total 125 patients with Rheumatoid Arthritis were interviewed. Participants gave valuations of their own health on a visual analogue scale (VAS) and time trade-off (TTO). To estimate persons' ability to adapt, patients filled in questionnaires measuring Self-esteem, Mastery, and Optimism. Finally they completed the SF-36 measuring HRQL. Regression analyses were used to investigate the direct and mediated effect of ability to adapt on health state utilities.</p> <p>Results</p> <p>Persons' ability to adapt did not add considerably to the explanation of health state utilities above HRQL. In the TTO no additional variance was explained by adaptive abilities (Δ R²= .00, β = .02), in the VAS a minor proportion of the variance was explained by adaptive abilities (Δ R²= .05, β = .33). The effect of adaptation on health state utilities seems to be mediated by the mental health domain of quality of life.</p> <p>Conclusions</p> <p>Patients with stronger adaptive abilities, based on their optimism, mastery and self-esteem, may more easily enhance their mental health after being diagnosed with a chronic illness, which leads to higher health state utilities.</p

Cervical cancer survivors’ and partners’ experiences with sexual dysfunction and psychosexual support

Cervix cancerGynecolog

Why do medical residents prefer paternalistic decision making?:An interview study

BACKGROUND: Although shared decision making is championed as the preferred model for patient care by patient organizations, researchers and medical professionals, its application in daily practice remains limited. We previously showed that residents more often prefer paternalistic decision making than their supervisors. Because both the views of residents on the decision-making process in medical consultations and the reasons for their ‘paternalism preference’ are unknown, this study explored residents’ views on the decision-making process in medical encounters and the factors affecting it. METHODS: We interviewed 12 residents from various specialties at a large Dutch teaching hospital in 2019–2020, exploring how they involved patients in decisions. All participating residents provided written informed consent. Data analysis occurred concurrently with data collection in an iterative process informing adaptations to the interview topic guide when deemed necessary. Constant comparative analysis was used to develop themes. We ceased data collection when information sufficiency was achieved. RESULTS: Participants described how active engagement of patients in discussing options and decision making was influenced by contextual factors (patient characteristics, logistical factors such as available time, and supervisors’ recommendations) and by limitations in their medical and shared decision-making knowledge. The residents’ decision-making behavior appeared strongly affected by their conviction that they are responsible for arriving at the correct diagnosis and providing the best evidence-based treatment. They described shared decision making as the process of patients consenting with physician-recommended treatment or patients choosing their preferred option when no best evidence-based option was available. CONCLUSIONS: Residents’ decision making appears to be affected by contextual factors, their medical knowledge, their knowledge about SDM, and by their beliefs and convictions about their professional responsibilities as a doctor, ensuring that patients receive the best possible evidence-based treatment. They confuse SDM with acquiring informed consent with the physician’s treatment recommendations and with letting patients decide which treatment they prefer in case no evidence based guideline recommendation is available. Teaching SDM to residents should not only include skills training, but also target residents’ perceptions and convictions regarding their role in the decision-making process in consultations

Antidepressants in primary care:patients' experiences, perceptions, self-efficacy beliefs, and nonadherence

PURPOSE: Patient adherence to antidepressants is poor. However, this is rather unsurprising, given the equivocal efficacy, side effects, and practical problems of antidepressants. The aim of this study was to examine a wide array of patient experiences and perceptions regarding the efficacy, side effects, and practical problems of antidepressants, as well as their associations with nonadherence, and whether patients' perceived self-efficacy moderated these associations.PATIENTS AND METHODS: Experiences and perceptions of 225 patients, recruited through community pharmacies, were efficiently assessed with the Tailored Medicine Inventory. Nonadherence was assessed through self-report and pharmacy refill data.RESULTS: Many patients were not convinced of the efficacy, thought the efficacy to be limited or did not believe antidepressants to prevent relapse, were worried about or had experienced one or more side effects, and/or had experienced one or more practical problems regarding information, intake, and packaging. Being convinced of efficacy was associated with lower intentional nonadherence (odds ratio [OR] 0.9, 95% confidence interval [CI] 0.8-0.96). A higher number of practical problems experienced was associated with increased unintentional nonadherence (OR 1.3, 95% CI 1.1-1.7). Higher perceived self-efficacy regarding taking antidepressants was associated with lower unintentional nonadherence (OR 0.7, 95% CI 0.5-0.9). Perceived self-efficacy did not moderate associations of patient experiences and perceptions with nonadherence.CONCLUSION: Assessing a wide array of patients' experiences and perceptions regarding the efficacy, side effects, and practical problems of antidepressants contributes to better understanding of nonadherence to antidepressants. Guiding physician-patient conversations by patients' experiences and perceptions may reduce both unintentional and intentional nonadherence. Also, it may give rise to considerations of prudent discontinuation, eg, when patients are not convinced of the efficacy.</p