Does training general practitioners result in more shared decision making during consultations?

Highlights

• Two training sessions of 2,5 h increases GP behaviour towards more shared decision making.

• GPs express a tension between guideline recommendations and the implementation of patient preferences.

• Taking the patient’s perspective into account remains troublesome for GPs.

Abstract

Objective

We conducted a clustered randomised controlled trial to study the effects of shared decision making (SDM) on patient recovery. This study aims to determine whether GPs trained in SDM and reinforcing patients’ treatment expectations showed more trained behaviour during their consultations than untrained GPs.

Methods

We compared 86 consultations conducted by 23 trained GPs with 89 consultations completed by 19 untrained GPs. The primary outcomes were SDM, as measured by the OPTION scale, and positive reinforcement, as measured by global observation. Secondary outcomes were the level of autonomy in decision making and the duration of the consultation.

Results

Intervention consultations scored significantly higher on most elements of the OPTION scale, and on the autonomy scale; however, they were three minutes longer in duration, and the mean OPTION score of the intervention group remained below average.

Conclusion

Training GPs resulted in more SDM behaviour and more autonomy for the patient; however, this increase is not attributable to the adoption of a patient perspective. Furthermore, while we aimed to demonstrate that SDM facilitates the reinforcement of patients’ positive expectations, the measurement of this behaviour was not reliable.

Practice implications

In supporting SDM, professionals should give greater attention to patients’ treatment expectations.

Introduction

In medical decisions, little attention is devoted to the patient perspective, and patients’ expectations often remain unnoticed [1], [2], [3]. This may have negative implications for recovery [4]. The concept of shared decision making (SDM), i.e., both the patient and the professional participate in the decision-making process and come to joint conclusions, is considered crucial for empowering patients to manage their healthcare problems and for overcoming this deficiency [5].

SDM may reinforce patients’ pre-existing ideas about recovery in treatment choices, and recovery may be facilitated if they have positive expectations [4], [6]. Thus, health professionals can contribute to better health outcomes by positively reinforcing patients’ recovery expectations through discussions of the benign spontaneous course [7]. Furthermore, health professionals can use a therapeutic approach to positively reinforce patients’ pre-existing positive ideas about recovery.

The aim of SDM is to increase patients’ autonomy in decisions about their personal health by shifting the doctor-patient relationship from a paternalistic to a more equal relationship [5]. Glyn Elwyn operationalised this concept into a 12-step process [8], [9]. In this broadly accepted model, patients are informed about the decision process and the pros and cons of treatment options. Then, patients’ concerns and expectations are explicitly explored and incorporated into the treatment choice before the treatment plan is mutually determined [8], [9].

Despite impressive scientific efforts, effective methods of implementing this approach remain unclear [9], [10], [11]. Further, current knowledge on effective methods of directing professional behaviour towards more patient-centred care and SDM is scarce and inconsistent [9], [11]. Effective methods of teaching physicians communication skills generally combine role-playing and feedback with small group discussions, and they should take at least one day [11]. Multifaceted interventions that include educating health professionals and decision aids, defined as instruments that prepare people to participate in decisions, are promoted to increase SDM behaviour [9]. Although these training sessions increase professionals’ performance in SDM process elements, such as listing options, patient care is not adequately adjusted to include patient preferences [3].

Time investment seems to be a necessary condition for implementing SDM because it is the most frequently mentioned barrier to introducing SDM into daily practice and because professionals’ level of performance is associated with the consultation duration [3], [10].

To promote general practitioners’ (GPs’) positive reinforcement of patients’ expectations, we developed a training program to teach GPs to implement SDM techniques and to positively reinforce the chosen therapy. This training program was part of an intervention study that compared the recovery of patients with low back pain who consulted a GP trained in SDM and in positively reinforcing the chosen therapy with the recovery of similar patients who consulted untrained GPs.

We assessed whether GPs who were trained in SDM and in positively reinforcing treatment expectations demonstrated better SDM and reinforcement skills during consultations with patients with low back pain than untrained GPs.