Restricted accessOtherFirst published online 2011-1
When the business of sharing treatment decisions is not the same as shared decision making: A discourse analysis of decision sharing in general practice
Although shared decision making (SDM) in general practice continues to be promoted as a highly desirable means of conducting consultations it is rarely observed in practice. The aim of this study is to identify the discursive features and conversational strategies particular to the negotiation and sharing of treatment decisions in order to understand why SDM is not yet embedded into routine practice. Consultations from Scottish general practices were examined using discourse analysis. Two themes were identified as key components for when the doctor and the patient were intent on sharing decisions: the generation of patient involvement using first-person pronouns, and successful and unsuccessful patient requesting practices. This article identifies a number of conversational activities found to be successful in supporting doctors’ agendas and reducing their responsibility for decisions made. Doctor’s use of ‘partnership talk’ was found to minimize resistance and worked to invite consensus rather than involvement. The information from this study provides new insight into the consultation process by identifying how treatment decisions are arrived at through highlighting the complexities involved. Notably, shared decision making does not happen with the ease implied by current models and appears to work to maintain a biomedical ‘GP as expert’ approach rather than one in which the patient is truly involved in partnership. We suggest that further research on the impact of conversational activities is likely to benefit our understanding of shared decision making and hence training in and the practice of SDM.
Atkinson JM, Heritage J. ( 1984) Structures of Social Action: Studies in Conversation Analysis . Cambridge: Cambridge University Press.
2.
Barry CA, Stevenson FA, Britten N., Barber N., and Bradley CP ( 2001) Giving Voice to the Lifeworld: More Humane, More Effective Medical Care? A Qualitative Study of Doctor- Patient Communication in General Practice. Social Science and Medicine53(4): 487-505.
3.
Blenkinsopp A., Bond C., and Britten N. ( 1997) From Compliance to Concordance: Achieving Shared Goals in Medicine Taking. London: Royal Pharmaceutical Society of Great Britain and Merck Sharp & Dohme.
4.
Bradley CP, Crowley M., Barry C., Stevenson FA, Britten N., and Barber N. ( 2000) Patient-Centredness and Outcomes in Primary Care. British Journal of General Practice50(451): 149.
5.
Charles C., Gafni A., Whelan T., and O’Brien MA (2006) Cultural Influences on the Physician- Patient Encounter: The Case of Shared Treatment Decision-Making . Patient Education and Counseling63(3): 262-267.
6.
Cromarty I. ( 1996) What Do Patients Think about During Their Consultations? A Qualitative Study. British Journal of General Practice46(410): 525-528.
7.
De Haes H. ( 2006) Dilemmas in Patient-Centredness and Shared Decision Making: A Case for Vulnerability. Patient Education and Counseling62(3): 291-298.
8.
Dowell J., Hudson H. ( 1997) A Qualitative Study of Medication-Taking Behaviour in Primary Care. Family Practice14(5): 369-375.
9.
Edwards A., Elwyn G., Smith C., Williams S., and Thornton H. ( 2001) Consumers’ Views of Quality in the Consultation and Their Relevance to ‘Shared Decision-Making’ Approaches. Health Expectations4(3): 151-161.
10.
Edwards A., Elwyn G., Hood K., et al. (2003) The Development of COMRADE: A Patient-Based Outcome Measure to Evaluate the Effectiveness of Risk Communication and Treatment Decision Making in Consultations. Patient Education & Counselling50(3): 311-322.
11.
Edwards D., Mercer NM ( 1987) Common Knowledge: The Development of Understanding in the Classroom. London: Routledge .
12.
Edwards D., Potter J. ( 1992) Discursive Psychology. London, Los Angeles, CA & New Delhi: SAGE.
13.
Elwyn G. ( 2006) Idealistic, Impractical, Impossible? Shared Decision Making in the Real World. British Journal of General Practice56(527): 403-404.
14.
Elwyn G., Charles C. ( 2001) Shared Decision-Making: The Principles and the Competences . In: Elwyn G, Charles C (eds) Evidence-Based Patient Choice: Inevitable or Impossible?Oxford: Oxford University Press, 118-143.
15.
Elwyn G., Gwyn R., Edwards A., and Grol R. ( 1999) Is ‘Shared Decision-Making’ Feasible in Consultations for Upper Respiratory Tract Infections? Assessing the Influence of Antibiotic Expectations Using Discourse Analysis. Health Expectations2(2): 105-117.
16.
Elwyn G., Edwards A., Wensing M., Hood K., Atwell C., and Grol R. ( 2003) Shared Decision Making: Developing the OPTION Scale for Measuring Patient Involvement. Quality and Safety in Health Care12(2): 93-99.
17.
Gravel K., Legare F., and Graham I. ( 2006) Barriers and Facilitators to Implementing Shared Decision-Making in Clinical Practice: A Systematic Review of Health Professionals’ Perceptions . Implementation Science9(1): 16.
18.
Halkowski T. ( 2007) Realizing the Illness. In: Heritage J, Maynard D (eds) Communication in Medical Care. Cambridge: Cambridge University Press, 86-114.
19.
Hamilton B., Manias E. ( 2006) She’s Manipulative and He’s Right Off: A Critical Analysis of Psychiatric Nurses’ Oral and Written Language in the Acute In-Patient Setting. International Journal of Mental Health Nursing15(2): 84-92.
20.
Heisler M., Bouknight RR, Hayward RA, Smith DM, and Kerr EA ( 2002) The Relative Importance of Physician Communication, Participatory Decision Making and Patient Understanding in Diabetes Self-Management. Journal of General Internal Medicine17(4): 243-252.
21.
Jefferson G. ( 1990) List Construction as a Task and Interactional Resource . In: Psathas G (ed.) Interaction Competence. Washington: International Institute for Ethnomethodology and Conversation Analysis/ University Press of America, 63-92.
22.
Kitzinger C., Frith H. ( 2001) Just Say No? The Use of Conversation Analysis in Developing a Feminist Perspective on Sexual Refusal. In: Wetherell M, Taylor S, and Yates SJ (eds) Discourse Theory and Practice: A Reader. London: SAGE, 167-185.
23.
Leech G., Svartvik J. ( 1975) A Communicative Grammar of English. London: Longman.
24.
Little P., Everitt H., Williamson I., et al. (2001) Observational Study of Effect of Patient Centredness and Positive Approach on Outcomes of General Practice Consultations . British Medical Journal323(7318): 908-911.
25.
Lock S., Last JM, and Dunea G. ( 2001) The Oxford Illustrated Companion to Medicine. Oxford: Oxford University Press.
26.
Makoul G., Clayman ML ( 2006) An Integrative Model of Shared Decision Making in Medical Encounters. Patient Education and Counseling60(3): 301-312.
27.
Mead N., Bower P. ( 2000) Patient-Centredness: A Conceptual Framework and Review of the Empirical Literature. Social Science & Medicine51(7): 1087-1110.
28.
Mol A. ( 2008) The Logic of Care: Health and the Problem of Patient Choice . London: Routledge.
29.
Murray E., Charles C., and Gafni A. ( 2006) Shared Decision-Making in Primary Care: Tailoring the Charles et al Model to Fit the Context of General Practice. Patient Education and Counseling62(2): 205-211.
30.
Nessa J., Malterud K. ( 1999) Discourse Analysis in General Practice: A Sociolinguistic Approach. Family Practice7(2): 77-83.
31.
Peräkylä A. ( 2007) Communicating and Responding to Diagnosis. In: Heritage J, Maynard DW (eds) Communication in Medical Care: Interaction between Primary Care Physicians and Patients. Cambridge: Cambridge University Press, 214-247.
32.
Potter J. ( 2000) Representing Reality: Discourse, Rhetoric and Social Construction . London, Los Angeles, CA & New Delhi: SAGE.
33.
Roberts C., Wass B., Srikant S., and Jones R. ( 2005) Misunderstandings: A Qualitative Study of Primary Care Consultations in Multilingual Settings, and Educational Implications. Medical Education39(5): 465-475.
34.
Robertson M. ( 2004) A Discourse Analysis of the Nature of Shared Decision Making in General Practice Consultations. Unpublished thesis, University of Dundee.
35.
Robinson JD ( 2007) Soliciting Patient’s Presenting Concerns. In: Heritage J, Maynard D (eds) Communication in Medical Care. Cambridge: Cambridge University Press, 22-47.
36.
Salmon P., Hall GM ( 2003) Patient Empowerment and Control: A Psychological Discourse in the Service of Medicine. Social Science & Medicine57(10): 1969-1980.
37.
Simon D, Loh A, and Harter M (eds) (2007) Measuring (Shared) Decision-Making: A Review of Psychometric Instruments. Z Arztl Fortbild Qualitatssich101: 259-267.
38.
Skelton JR, Wearn AM, and Hobbs FR ( 2002) ‘I’ and ‘We’: A Concordancing Analysis of How Doctors and Patients Use First Person Pronouns in Primary Care Consultations. Family Practice19(5): 484-488.
39.
Stivers T. ( 2006) Treatment Decisions: Negotiations between Doctors and Parents in Acute Care Encounters. In: Heritage J, Maynard DW (eds) Communication in Medical Care: Interaction between Primary Care Physicians and Patients. Cambridge: Cambridge University Press, 279-312.
40.
Stivers T., Heritage J. ( 2001) Breaking the Sequential Mould: Answering More Than the Question during Comprehensive History Taking. Text21(1): 151-158.
41.
Ten Have P. ( 2001) Lay Diagnosis in Interaction. Text21(1-2): 251-260.
42.
Towle A., Godolphin WA ( 1999) Framework for Teaching and Learning Informed Shared Decision-Making . British Medical Journal319(7212): 7666-7671.
43.
Towle A., Godolphin W., Grams G., and LaMarre A. ( 2006) Putting Informed and Shared Decision Making into Practice . Health Expectations9(4): 321-332.
