Shared decision-making in primary care: Tailoring the Charles et al. model to fit the context of general practice

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Abstract

Objective

To explore the application of the original Charles et al. model of shared treatment decision-making [Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med 1997;44:681–92; Charles C, Gafni A, Whelan T. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med 1999;49:651–61] in the context of general practice, and to determine whether the model needs tailoring for use in this clinical context.

Methods

Conceptual paper, presenting the defining characteristics of general practice compared to the original clinical context for which the model was developed (i.e. life threatening disease with different treatment options), and exploring how the model can be tailored for use in the context of general practice.

Results

We identify two areas where the original model requires tailoring: sharing the decision-making around agreeing on an agenda for each consultation; and adapting the information transfer component of the model to acknowledge that doctors may not be the only, or even the main, source of technical information for patients. Finally, we explore the importance of shared decision-making in the context of chronic disease.

Conclusion

The Charles et al. model can be tailored for use in general practice.

Practice implications

Tailoring the model for use in general practice has implications for research, in terms of identifying the additional physician competencies needed for implementation. Policy makers who wish to promote shared decision-making need to ensure that incentives which prioritize access and health outcomes do not militate against shared decision-making in general practice.

Introduction

Shared decision-making between health professionals and patients is becoming increasingly topical and important in the research and health policy arenas. In the UK, the General Medical Council considers one of the key duties of a doctor to: “respect the rights of patients to be fully involved in decisions about their care” [3], while health policy documents actively promote shared decision-making [4], [5], [6]. The World Health Organisation (WHO) considers “autonomy with respect to a person's participation in choices about their own health” to be an important quality marker for health care systems [7]. In addition, there is a growing body of academic research on shared decision-making, reflected in the bi-annual International Shared Decision-Making Conference (http://decisionaid.ohri.ca/ISDM2005/).

The framework developed by Charles et al. for defining the meaning of shared treatment decision-making originated in the context of “a life threatening disease where several treatment options were available with different possible outcomes” using specialist oncology practice for early stage breast cancer as a specific example [1], [2]. This original clinical context within which the framework was developed is often forgotten, and the question of whether a framework devised in one clinical context can reasonably be applied to other clinical contexts has rarely been addressed. One way of exploring the generalisability of the framework is to explore its application in a different clinical context and to determine whether the framework adequately describes shared clinical decision-making in this new context.

Shared treatment decision-making as conceptualized by Charles et al. lies in between a paternalistic and an informed decision-making model. This conceptualisation highlights the importance of three components to the decision-making process: information exchange; deliberation; negotiation about, and agreement to implement, a treatment decision (Box 1). In a pure paternalistic model, the doctor makes health care decisions based on what she believes to be the best interests of the patient. Information transfer is one way and limited to the doctor providing bio-medical information about the chosen treatment to the patient. Any deliberations about the treatment are undertaken by the doctor alone, or in collaboration with other clinicians. At the other extreme is the pure informed model, where patients make the decisions about their own health care. Again, information transfer is one way, with the doctor providing all the information the patient needs about the various treatment options to make a decision. Deliberation is by the patient alone, or the patient in collaboration with friends or family.

Shared decision-making lies between these two extremes. Information transfer is two way: the doctor provides all the medical information needed to make a decision, while the patient provides information about, for example, her personal circumstances, and which outcomes are of greatest personal importance. The doctor also states her values, so that the patient can understand where the doctor is coming from. The doctor and patient deliberate together, discuss how the various treatment options meet the patient's and doctor's priorities and reach a joint decision [1], [2].

In this paper, we explore the Charles et al. framework of shared treatment decision-making in the context of general practice. General practice has a number of defining characteristics. We describe these below. We illustrate how these characteristics can manifest with clinical vignettes drawn from the first author's clinical practice. We then explore how the original Charles et al. framework can be applied in these clinical vignettes, and demonstrate how the framework needs tailoring for use in this context.

Section snippets

Defining characteristics of general practice

Although general practice does vary from country to country, many of the key features are common internationally [8]. We have opted to describe general practice in the UK as our specific example of the general practice context.

Application of the shared treatment decision-making model to general practice

Now that we have identified some of the characteristics of consultations in general practice in terms of undifferentiated symptoms, multiple diagnoses, bio-psycho-social approaches, care in the context of an on-going therapeutic relationship, and care of families and populations, it is worth looking at how to apply the Charles et al. shared treatment decision-making framework to general practice.

The framework described by Charles et al. focuses on defining the level and type of involvement of

Discussion

In this paper, we have examined the clinical context of general practice, and shown how the original Charles et al. framework can be tailored for use in this clinical context. The core components of the original model, i.e. information exchange, deliberation, and negotiation and implementation of a decision are applicable; however, the decisions faced are not limited to simple treatment decisions, and the doctor's role in information exchange may include encouraging the patient to seek out

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