Elsevier

Social Science & Medicine

Volume 56, Issue 3, February 2003, Pages 589-602
Social Science & Medicine

What are the ingredients for a successful evidence-based patient choice consultation?: A qualitative study

https://doi.org/10.1016/S0277-9536(02)00056-4Get rights and content

Abstract

The evidence-based patient choice (EBPC) approach is one of a number of newly emerging templates for medical encounters that advocate evidence-informed choice and shared decision-making. These models emphasise respect for patient preferences for involvement in health care decisions and advocate the sharing of good quality evidence-based information. In the medical consultation EBPC involves providing patients with evidence-based information in a way that facilitates their ability to make choices or decisions about their health care. Whereas the key principles of shared decision-making have been conceptualised, so far, no qualitative investigations have been undertaken to establish the key components of an EBPC consultation. Therefore, a series of semi-structured interviews were carried out with key informants to identify the elements and skills required for a successful EBPC consultation to occur. The interviews were conducted with purposively selected UK general practitioners (n=11), hospital doctors (n=10), practice nurses (n=5), academics (n=11) and lay people (n=8). Qualitative analysis of participants’ responses was conducted using the constant comparative method. Six main themes emerged from the data, these were research evidence/medical information, the doctor–patient relationship, patient perspectives, decision-making processes, time issues and establishing the patient's problem. All respondents placed importance on doctors and patients being well informed and appraised of the latest available medical evidence. There was a general view that evidence-based information regarding diagnosis and treatment options should be shared with patients during a consultation. However, there were no suggestions as to how this might be achieved in practice. Participants’ opinions relating to which model of decision-making should be adopted ranged from favouring an informed choice model, to the view that decision-making should be shared equally. Similarly, there was no clear view on how much guidance a doctor should offer a patient during decision-making concerning the most appropriate treatment option for that patient.

Introduction

The term “evidence-based patient choice” (EBPC) was first described by Hope (1996) as the merging together of two important modern movements in western health care, namely evidence-based medicine and patient-centred care. This approach is one of several newly emerging models of the medical encounter which advocate evidence informed patient choice (Entwistle, Sheldon, Sowden, & Watt, 1998; Towle & Godolphin, 1999) and shared decision-making (Braddock, Edwards, Hasenberg, Laidley, & Levinson, 1999; Charles, Gafni, & Whelan (1997), Charles, Gafni, & Whelan (1999); Elwyn, Edwards, Kinnersley, & Grol, 2000). EBPC is not limited to what has been termed the “neglected second half of the consultation” (Elwyn, Edwards, & Kinnersley, 1999), like most other approaches it encompasses the whole consultation of which an important component is patient involvement in decision-making.

Evidenced-based medicine (EBM) requires the use of current best evidence to make decisions about the care of individual patients (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). Clinical interventions are recommended on the strength of evidence for their effectiveness derived mostly from randomised-controlled trials and systematic reviews. Five basic tenets of EBM have been identified:

  • 1.

    clinical decisions should be based on the best available scientific evidence,

  • 2.

    the clinical problem determines the evidence to be sought,

  • 3.

    identifying the best evidence involves epidemiological and biostatistical ways of thinking,

  • 4.

    conclusions based on the available evidence are useful only if put into action for individual patients or for population health care decisions,

  • 5.

    performance should be constantly evaluated (Davidoff, Haynes, Sackett, & Smith, 1995).

However, in this biomedical approach the individual qualities, needs and preferences of patients have tended to be neglected as relevant factors in the decision-making process (Bensing, 2000). Whilst, EBM addresses the biomedical perspective of diagnosis, mostly from a doctor-centred paradigm (Jacobson, Edwards, Granier, & Butler, 1997), doctors also need evidence that is derived from a patient-centred paradigm that takes into account the personal and contextual elements of decision-making in practice. Patient-centred medicine, is derived from a humanistic, biopsychosocial perspective and combines ethical values on the “ideal doctor”, with psychotherapeutic theories on the facilitation of patients’ disclosure of concerns and negotiation theories on decision-making (Bensing, 2000). This model of care places a strong emphasis on patient participation in clinical decision-making by taking into account the patient's needs and preferences. Therefore, in order for cognitively competent patients to have the power to make evidence-based choices, as well as being evidence-based, the medical consultation must be “patient-centred”. Providing patients with evidence-based knowledge should enhance their power and aid the development of an increasingly effective patient-centred health care system (Hope, 1996). However, there is a need to ensure that evidence-based information is conveyed to patients in a way that will increase their understanding and enable them to make informed choices about their treatment and management. In the medical consultation, evidence-based patient choice requires providing patients with good quality information to facilitate their ability to make choices or decisions about their health care. The original theory combines evidence-based medicine with patient-centred care, so that information that is of value and personal importance to patients when making choices (e.g. process of delivery of care) is considered in parallel with scientific evidence-based information. However, the term “evidence-based” is increasingly becoming outdated as consensus grows that EBM should acknowledge multiple dimensions of evidence including practical evidence based on individuals’ interpretation of experience (Buetow & Kenealy, 2000). Therefore, evidence-based patient choice must embrace a broader definition of EBM that includes evidence produced outside science.

The concept of “patient choice” originates from the doctrine of informed consent. In English and US law a competent person has a legal right to refuse treatment (even life saving). Valid consent is achieved only if the individual concerned has been given the relevant information. Over the last 20 years, medical ethicists have stressed the importance of the principle of patient autonomy (Veatch, 1982; Brody, 1985; Dworkin, 1988; Quill & Brody, 1996). This emphasises that patients should be in a position to choose whether to accept an intervention or not as part of their general right to determine their own lives (Hope, 1996). A central ethical principle behind evidence-based patient choice is that the information is being given in order to enhance choice. Patient choice goes beyond consent and involves the patient in the decision-making process. However, the move towards increasing patient involvement is not driven simply by a theoretical concern for respect for patient autonomy. Rather, it is a recognition of the fact that individuals differ both in what they value and in their propensity to take risks (Hope, 1996).

Models of shared decision-making and EBPC reflect a growing trend in health care towards patient empowerment and greater patient choice (Department of Health, 2000). This has been fostered by the increasing patient access to information about treatments and the consumerist trends in modern society (Ballard-Reisch, 1993; Elwyn et al., 1999). Over the last 20 years or so there has been a call for more patient choice and personal control in medical care (Reiser, 1993). Current National Health Service (NHS) initiatives advocate “active partnerships” between health professionals and patients (NHS Executive, 1996) and the improvement of information to help patients choose between options (NHS Executive, 1995). Nowadays, most theorists acknowledge that unilateral decision-making by doctors is unacceptable (except in certain situations, for example, when a patient is comatose or in urgent need of life-saving action). The old paternalistic models of doctor–patient relations have been rejected by policy makers, and medical academics in favour of more equitable and collaborative relationships characterised by informed choice. There is a growing consensus that sharing decisions is desirable on humanistic grounds alone (Guadagnoli & Ward, 1998).

There is also empirical evidence that giving patients information and involving them in decisions about their health care can result in beneficial psychological and physical outcomes. For example, enhanced patient satisfaction Roter (1983), adherence to treatment plans (Janis, 1982), greater confidence in health care recommendations (Brody, 1980), psychological adjustment to illness (Fallowfield, Hall, Maguire, & Baum, 1990) and symptom resolution (Bass et al., 1986). It has also been found that if patients are actively involved in making decisions about their care, physiological outcomes such as diabetic control can be improved (Greenfield, Kaplan, Ware, Yano, & Frank, 1988). Further evidence suggests that allowing patients to choose their medical treatment can enhance psychological well-being (Ashcroft, Leinster, & Slade, 1986; Fallowfield, Hall, Maguire, & Baum (1990), Fallowfield et al. (1994)).

In her comprehensive review of health outcomes, Stewart (1995) concluded that four key dimensions of communication were related to positive patient outcomes (emotional health, symptom resolution, function and physiological health):

  • the provision of clear information,

  • questions from the patient,

  • willingness to share (discuss) decisions,

  • agreement between patient and doctor about the problem and the plan.

There is also evidence that giving patients information about the choices open to them can sometimes lead to fewer prescriptions for specific drugs such as warfarin (Protheroe, Fahey, Montgomery, & Peters, 2000) and less demand for some surgical treatments as in the case of benign prostatic hyperplasia (Barry, Fowler, Mulley, Henderson, & Wennberg, 1995).

However, there are other studies that show that although patients prefer patient-centred care, it does not necessarily enhance physiological outcome. For example Kinmonth, Woodcock, Griffin, Spiegal, & Campbell (1998) carried out an intervention study to assess the effect of additional training of practice nurses and GPs (for abbreviation see Fig. 1) in patient-centred care on outcomes of patients with newly diagnosed type 2 diabetes. In this study patients in the intervention group reported better communication with doctors, greater treatment satisfaction and wellbeing than the comparison group. However, their body mass index was significantly higher as were triglyceride concentrations. There is a clear need for more robust studies to investigate the effects of patient involvement in different disease groups on a variety of health care outcomes, including those of a psychological, physiological and financial nature.

Little is known about patients’ preferences for evidence-based information during consultations. The limited work in this area suggests that for some conditions, the majority of patients value being given information about the effectiveness of treatment and care options (Wagner, Barrett, Barry, Barlow, & Fowler 1995). Inevitably patient preferences are increasingly being influenced by the consumerist trends in modern society which, in turn, have fostered better access to medical information. Developments in Britain such as local consumer health information services (Sheppard, Charnock, & Gann, 1999) have improved awareness of, and access to, evidence-based consumer health information. More recently, innovations such as the recently launched National Electronic Library for Health (NeLH) (Muir Gray & de Lusignan, 1999), now provide health professionals and patients with easy access to the most up-to-date evidence of the effectiveness of health-care interventions. Not surprisingly, patients are becoming increasingly better informed about health care issues and expect to be given comprehensive information concerning their diagnosis, prognosis and treatment options (Jenkins et al., 2001).

Despite the current trends that advocate greater patient involvement in health care, whether patients actually want this is yet to be conclusively demonstrated. For example, Savage and Armstrong (1990) conducted a study involving 359 randomly selected patients consulting with one general practitioner to compare the effect of directing and sharing styles of consultation on patient satisfaction. The authors found that patients in the directive group with self-limiting problems or chronic conditions and those receiving a prescription, reported significantly higher levels of satisfaction on several outcome measures. These included: satisfaction with the GPs perceived understanding of their problem and the explanation they received.

The results of a study investigating Australian, UK and US preferences for participation in medical decision-making suggested that mutuality was the preferred method of decision-making for participants in all 3 countries (Smith, Garko, Bennett, Irwin, & Schofield, 1994). The authors found that if the question was asked, “Do patients prefer to decide for themselves or delegate decisions to their doctors?” participants chose to delegate, but if respondents were asked if they preferred joint decision-making, delegating or deciding they preferred joint decisions.

Most of the empirical research evaluating patient preferences for participation has been conducted in North America using “high stake” scenarios, for example, decisions concerning treatment for cancer. Therefore, it is not known whether these findings can be applied to other patient populations and different medical contexts, such as patients in general practice. Much of the research is based on surveys using different assessment measures which makes comparisons difficult (Deber (1994a), Deber (1994b); Guadagnoli & Ward, 1998). Studies conducted using hypothetical questions or contrived scenarios may not truly reflect patients’ preferences during a real clinical interview.

The desire to be involved (or not) in decision-making may depend on the type and severity of a patient's condition. For example, Beaver et al. (1996) surveyed 150 women recently diagnosed with breast cancer using a role-preference card-sort (Degner & Sloan, 1992) which consisted of five cards with a written statement and cartoon depicting increasing levels of patient involvement. The women were asked to choose their preferred decision-making role from all possible pairings of the five cards (ten in total). Results showed that 20% wanted an active role in deciding their treatment, 28% preferred a joint decision, and just over half (52%) wanted their surgeon to decide for them. In contrast a control group of patients with benign breast disease wanted to share responsibility for decision-making with the surgeon. The cancer patients were assessed at an early stage and had no definite knowledge about their type of cancer, prognosis or treatment. Therefore, this lack of information may have contributed to their reluctance to be more involved in the decision-making process. In an extension of the above study (Beaver, Bogg, & Luker, 1999) a comparison of the decision-making preferences and information needs of colorectal (n=48) versus breast cancer patients (n=150) was conducted. Once again a decisional role preference card sort was used and an information needs questionnaire. It was found that the majority (78%) of the colorectal patients preferred to play a passive role in decision-making, in contrast to 52% of the breast cancer patients. Of note is the fact that both groups had similar information needs relating to cure, spread of disease and treatment options.

The majority of patients’ desire for information is stronger than their desire to be involved in decision-making (Ende, Kazis, Ash, & Moskowitz, 1989; Strull, Lo, & Charles, 1984; Degner et al., 1997; Beaver et al., 1999). Furthermore, many patients would like to receive more information than they currently do from health care professionals (Audit Commission, 1993; Meredith et al., 1996). Whether they wish to be involved in decision-making or not, patients increasingly expect to be told their diagnosis and details concerning pathophysiology, treatment options and prognosis (Laine & Davidoff, 1996; Meredith et al., 1996).

The purpose of this qualitative study was to identify the elements and skills required for a successful EBPC consultation to occur. We stress that we were testing reactions to a theoretical concept rather than to the actual existence of the EBPC consultation. The key principles of shared decision-making have already been conceptualised (Charles et al., 1997; Towle & Godolphin, 1999). However, no qualitative investigations have yet been undertaken to establish the key components of an EBPC consultation. Therefore, a series of semi-structured interviews were carried out with key informants in an attempt to establish these criteria.

Section snippets

Methods and sample

Purposeful sampling was used to recruit participants who were anticipated to be good informants, i.e., those likely to have an interest in patient involvement in decision-making, evidence-based medicine and patient-centred care. Those invited to take part included UK general practitioners, hospital doctors, academics, lay people and nurse practitioners. The GPs and hospital doctors were medical student tutors affiliated to the UK Oxford medical communication skills teaching programme. Academics

Analysis and coding

The interviews were analysed using the constant comparison method, a qualitative technique which involves the systematic sifting and comparison of items of recorded data to reveal and establish the mutual relationships and internal structure of categories (Green, 1998). Responses were transcribed and divided into simpler text units that were entered into a database for ease of coding. Units of text (at least one complete thought) referring to similar issues were separated from dissimilar units

Results

Overall, participants had a clear understanding of the theoretical principles behind evidence-based patient choice, but perhaps unsurprisingly, were less clear about the specific processes that might be involved to achieve it during a medical consultation. Furthermore, GPs and hospital doctors in particular were rather sceptical about the successful application of this model in practice. This scepticism was reinforced by the expression of several types of barriers to the implementation of this

Research evidence/medical information

All respondents placed importance on doctors being well informed and appraised of the latest available medical evidence. It was also considered desirable for doctors to have fast and easy access to reliable sources of evidence, e.g. “an NHS desk-top computer link to the latest research evidence”. Related to this, a need was identified for doctors to be trained in computerised data retrieval and to attend training courses on how to practice evidence-based medicine. Critical appraisal skills were

Doctor–patient relationship

The general characteristics of the doctor–patient relationship concerned issues, which ideally should be present in any doctor–patient encounter such as trust, respect, honesty and partnership building. These issues were mentioned by the majority of respondents in each group, exemplified by the following statements:

There should be openness and trust between a doctor and a patient. [NP5]

The patient should be treated as an individual and an equal partner. [GP5]

The relationship between a doctor

Patient's perspective

Forty two respondents made at least one comment which related to issues concerning the patient's perspective. Responses related mostly to exploring patients’ individual qualities and circumstances. Gaining an understanding of the patient's perspective during a consultation involved “exploration” and “consideration” of “expectations”, “assumptions”, “anxieties”, “concerns”, “beliefs and values”. This was linked to “elicitation of the patient's agenda” and “establishing patient ideas and level of

Decision-making process

Responses concerning the decision-making process were divided into 4 categories relating to: model of decision-making, pre-decision deliberations, level of doctor guidance versus patient autonomy and post-decision tasks. Thirty five respondents made at least 1 comment for this theme. A range of descriptors was used to describe the ideal model for deciding the appropriate treatment for a patient. For example:

The patient must be given the chance to make an informed choice if he or she wants to.

Time issues

Overwhelmingly, it was considered important to have enough time to practice the EBPC approach. In particular, plenty of time is needed during the consultation to “find and discuss the evidence”. It was also felt that a doctor should be willing to see a patient on more than one occasion to “discuss the evidence and options”. One GP said: “ideally consultation length should not be an issue as patients need time to talk and ask questions about options”. Another lay expert believed that “patients

Establishing nature of the problem

This theme was the smallest in terms of the number of contributing respondents. This may be because it was taken for granted that the primary purpose of the doctor during any consultation is to ascertain the patient's reason for attending. At least 1 member of each response group is represented. GPs responses predominate followed by those of hospital doctors. A common response concerned obtaining the “full story” from the patient in conjunction with checking “family history”, “background” and

Discussion

The analysis of 45 semi-structured interviews brought to light 6 main themes relating to the essential ingredients for an EBPC consultation (see Fig. 2). Some categories were difficult to delineate and as a result there is some overlap between some of the themes. For example, recurrent responses running through several themes were the importance of eliciting the patient's perspective and good communication skills for the health professional. The elicitation of the patient's values is a

Acknowledgements

We thank all those who gave their time to participate in the interviews and our colleagues who gave advice throughout the study, in particular Professor Paul Salkovskis and Joyanne MacInnes. This project was funded by the NHS Anglia and Oxfordshire Regional R & D.

References (72)

  • M.J. Bass et al.

    The physician's actions and the outcome of illness in family practice

    Journal of Family Practice

    (1986)
  • K. Beaver et al.

    Decision-making role preferences and information needsA comparison of colorectal and breast cancer

    Health Expectations

    (1999)
  • K. Beaver et al.

    Treatment decision making in women newly diagnosed with breast cancer

    Cancer Nursing

    (1996)
  • H.B. Beckman et al.

    The effect of physician behavior on the collection of data

    Annals of Internal Medicine

    (1984)
  • A.E. Beisecker et al.

    Patient information-seeking behaviours when communicating with doctors

    Medical Care

    (1990)
  • J. Bird et al.

    Workshops for consultants on the teaching of clinical communication skills

    Medical Education

    (1993)
  • C.H. Braddock et al.

    Informed decision making in outpatient practice

    Journal of the American Medical Association

    (1999)
  • D.S. Brody

    The patient's role in clinical decision making

    Annals of Internal Medicine

    (1980)
  • H. Brody

    Autonomy revisited: Progress in medical ethicsDiscussion paper

    Journal of the Royal Society of Medicine

    (1985)
  • S. Buetow et al.

    Evidence-based medicineThe need for a new definition

    Journal of Evaluation in Clinical Practice

    (2000)
  • A. Coulter et al.

    Informing patientsAn assessment of the quality of patient information materials

    (1998)
  • F. Davidoff et al.

    Evidence based medicine. A new journal to help doctors identify the information they need

    British Medical Journal

    (1995)
  • R.B. Deber

    The patient-physician partnershipChanging roles, and the desire for information

    Canadian Medical Association Journal

    (1994)
  • R.B. Deber

    The patient-physician partnershipDecision making, problem solving, and the desire to participate

    Canadian Medical Association Journal

    (1994)
  • L.F. Degner et al.

    Information needs and decisional preferences in women with breast cancer

    Journal of the American Medical Association

    (1997)
  • Department of Health (2000). The NHS Plan. A plan for investment. A plan for reform. London: Stationery...
  • G. Dworkin

    The theory and practice of autonomy

    (1988)
  • A. Edwards et al.

    General practice registrar responses to the use of different risk communication toolsProblems and opportunities

    British Medical Journal

    (1999)
  • G. Elwyn et al.

    Shared decision-making in primary careThe neglected second half of the consultation

    British Journal of General Practice

    (1999)
  • G. Elwyn et al.

    Shared decision making and the concept of equipoiseThe competences of involving patients in healthcare choices

    British Journal of General Practice

    (2000)
  • E.J. Emanuel et al.

    Four models of the physician-patient relationship

    Journal of the American Medical Association

    (1992)
  • J. Ende et al.

    Measuring patients’ desire for autonomyDecision-making and information-seeking preferences among medical patients

    Journal of General Internal Medicine

    (1989)
  • V.A. Entwistle et al.

    Evidence-informed patient choicePractical issues of involving patients in decisions about health care technologies

    International Journal of Technology Assessment in Health Care

    (1998)
  • L.J. Fallowfield et al.

    Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial

    British Medical Journal

    (1990)
  • L.J. Fallowfield et al.

    Psychological effects of being offered choice of surgery for breast cancer

    British Medical Journal

    (1994)
  • L. Fallowfield et al.

    Teaching senior oncologists communication skillsResults from phase i of a comprehensive longitudinal program in the united kingdom

    Journal of Clinical Oncology

    (1998)
  • Cited by (146)

    View all citing articles on Scopus
    View full text