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Communication between primary care patients and their doctors does not necessarily result in shared decisionmaking

During primary care visits, communication between the patient and physician can "look good," but it does not always "feel good," reveals a study supported in part by the Agency for Healthcare Research and Quality (HS10856). Over one-third of the time (38 percent), patients and physicians exchanged information and beliefs and appeared to make joint decisions. However, their subjective experience was negative and the relationship was characterized by mistrust, withholding of crucial information, or mutual frustration. For example, the patient had not told the doctor he was not taking his medicine or the doctor was frustrated with a patient, but had not told him so.

The researchers directly observed and videotaped 18 visits between experienced primary care physicians and predominantly low-income minority patients at three clinics. Patients and physicians were independently asked about their discussions of treatment options during recall sessions where they viewed the videotaped encounters. The researchers coded decision moments for objective evidence of shared decisionmaking (SDM present or not) and positive subjective experience or not. SDM consisted of five behaviors: offering beliefs, eliciting beliefs, offering information, eliciting information, and reaching closure.

The 18 visits yielded 125 decisions, 50 percent of which demonstrated SDM. Analysis of 82 decisions discussed in stimulated recall resulted in 4 archetypes of engagement in decisionmaking: full engagement (SDM present, positive subjective experience), 22 percent; simulated engagement (SDM present, negative subjective experience), 38 percent; assumed engagement (SDM absent, positive subjective experience), 21 percent; and nonengagement (SDM absent, negative subjective experience), 19 percent. These findings suggest that communication behavior does not ensure an experience of collaboration, and a positive subjective experience of partnership does not reflect full communication.

More details are in "Shared decision making and the experience of partnership in primary care," by George W. Saba, Ph.D., Sabrina T. Wong, R.N., Ph.D., Dean Schillinger, M.D., and others, in the January 2006 Annals of Family Medicine 4(1), pp. 54-62.

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