Putting informed and shared decision making into practice

OBJECTIVE: To investigate the practice, experiences and views of motivated and trained family physicians as they attempt to implement informed and shared decision making (ISDM) in routine practice and to identify and understand the barriers they encounter. BACKGROUND: Patient involvement in decision making about their health care has been the focus of much academic activity. Although significant conceptual and experimental work has been done, ISDM rarely occurs. Physician attitudes and lack of training are identified barriers. DESIGN: Qualitative analysis of transcripts of consultations and key informant group interviews. SETTINGS AND PARTICIPANTS: Six family physicians received training in the ISDM competencies. Audiotapes of office consultations were made before and after training. Transcripts of consultations were examined to identify behavioural markers associated with each competency and the range of expression of the competencies. The physicians attended group interviews at the end of the study to explore experiences of ISDM. RESULTS: The physicians liked the ISDM model and thought that they should put it into practice. Evidence from transcripts indicated they were able to elicit concerns, ideas and expectations (although not about management) and agree an action plan. They did not elicit preferences for role or information. They sometimes offered choices. They had difficulty achieving full expression of any of the competencies and integrating ISDM into their script for the medical interview. The study also identified a variety of competency-specific barriers. CONCLUSION: A major barrier to the practice of ISDM by motivated physicians appears to be the need to change well-established patterns of communication with patients.