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

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

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

VWF/ADAMTS13 Imbalance, But Not Global Coagulation or Fibrinolysis, Is Associated With Outcome and Bleeding in Acute Liver Failure

Background and Aims Recent studies of acute liver failure (ALF) in man and animals have suggested that rebalanced hemostasis occurs, with distinct hypercoagulable features clinically evidenced by a low risk of bleeding. Rodent models have shown a link between intrahepatic microthrombus formation and progression of ALF. We sought to confirm these earlier findings in a large series of patients with well-characterized ALF from the Acute Liver Failure Study Group.Approach and Results Citrated plasma samples taken on admission from 676 patients with ALF or acute liver injury (international normalized ratio &gt;= 2.0 without hepatic encephalopathy) were used to determine levels of von Willebrand factor (VWF), a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) activity, thrombomodulin-modified thrombin generation, and clot lysis time (CLT) and compared with the levels in 40 healthy controls. Patients had 3-fold increased VWF levels, 4-fold decreased ADAMTS13 activity, similar thrombin generating capacity, and 2.4-fold increased CLT, compared with controls. Increasing disease severity was associated with progressively more elevated VWF levels as well as hypofibrinolysis. Patients who died or underwent liver transplantation within 21 days of admission had higher VWF levels, lower ADAMTS13 activity, but similar thrombin generation and a similar proportion of patients with severe hypofibrinolysis, when compared with transplant-free survivors. Likewise, patients with bleeding complications had higher VWF levels and lower ADAMTS13 activity compared to those without bleeding. Thrombin generation and CLT did not differ significantly between bleeding and nonbleeding patients.Conclusions Rebalanced hemostatic status was confirmed in a large cohort of patients with acute liver injury/ALF, demonstrating that VWF/ADAMTS13 imbalance is associated with poor outcome and bleeding. The association between VWF/ADAMTS13 imbalance and bleeding suggests that bleeding in ALF relates more to systemic inflammation than a primary coagulopathy.</p

Shared decision making:Physicians' preferred role, usual role and their perception of its key components

Objective: To investigate physicians’ preferred and usual roles in decision making in medical consultations, and their perception of shared decision making (SDM). Methods: A cross-sectional survey of 785 physicians in a large Dutch general teaching hospital was undertaken in June 2018, assessing their preferred and usual decision making roles (Control Preference Scale), and their view on SDM key components (SDMQ9 questionnaire). Results: Most physicians (n = 232, 58%) preferred SDM, but more often performed paternalistic decision making (n = 121, 31%) in daily practice than they preferred (n = 80, 20%, p < 0.0001), most commonly because they judged the patient to be incapable of participating in decision making. Most physicians preferring SDM presented different options for treatment (n = 213, 92%) with their advantages and disadvantages (n = 209, 90%) but fewer made clear that a decision had to be made (n = 104, 45%) or explored the patient's wish how to be involved in decision making (n = 80, 34%). Conclusion: Although most physicians prefer SDM, they often revert to a paternalistic approach and tend to limit SDM to discussing treatment options. Practice implication: Teaching physicians in SDM should include raising awareness about discussing the decision process itself and help physicians to counter their tendency to revert to paternalistic decision making in daily practice

Observational study on the timing and method of interruption by hospital consultants during the opening statement in outpatient consultations

Objective To analyse verbal interruptions by Dutch hospital consultants during the patient’s opening statement in medical encounters.Design Cross-sectional descriptive study.Setting Isala teaching hospital in Zwolle, the Netherlands.Participants 94 consultations by 27 consultants, video recorded in 2018 and 2019.Main outcome measures Physicians’ verbal interruptions during patients’ opening statements, rate of completion of patients’ opening statements, time to first interruption and the effect of gender, age and physician specialty on the rate and type of physicians’ verbal interruptions.Results Patients were interrupted a median of 9 times per minute during their opening statement, the median time to the first interruption was 6.5 s. Most interruptions (67%) were backchannels (such as ‘hm hm’ or ‘go on’), considered to be encouraging the patient to continue. In 52 consultations (55%), patients could not finish their opening statement due to a floor changing interruption by the consultant. The median time to such an interruption was 31.4 s, on average 20 s shorter than a finished opening statement (p=0.004). Female consultants used more backchannels (median 9, IQR 5–12) than male consultants (median 7, IQR 2–11, p=0.028).Conclusions Hospital-based consultants use various ways to interrupt patients during their opening statements. Most of these interruptions are encouraging backchannels. Still, consultants change the conversational floor in more than half of their patients during their opening statements after a median of 31 s