Analysis showed significant differences in OPTION scores between French and English consultations (French OPTION mean = 25% ± 8%; English OPTION mean = 22% ± 7%; t = 2.79, P = .006). It also showed significant differences between consultations with male and female practitioners (female OPTION mean = 25% ± 8%; male OPTION mean = 22% ± 7%; t = 2.08, P = .04). We observed a positive correlation between the OPTION score and the duration of consultation (r = 0.24, P = .003). The mean duration of a consultation (only including time with the patient, not time with a supervisor) was 0:28:41, SD ± 0:13:43. The minimum and maximum consultation times were 0:04:45 and 1:13:47, respectively. Considering that French consultations lasted significantly longer than English consultations (average duration of a consultation: French = 36 ± 13 minutes, English = 20 ± 9 minutes; t = 9.44, P < .0001) and that female residents' consultations lasted significantly longer than male residents' consultations (average duration of a consultation: female resident = 31 ± 14 minutes; male resident = 24 ± 12 minutes; t = 2.69, P = .008), we adjusted for time. After this adjustment, we observed no difference in OPTION scores according to the language of the consultation (P = .21) or the gender of the resident (P = .13). This indicates that the duration of the consultation can influence scores.
Family medicine residents who had obtained an academic degree prior to their medical education obtained lower OPTION scores than those who had not obtained such a degree (mean for those having a prior degree = 22% ± 7%; n = 62; 95% CI = 19.9%–23.2%; mean for those without a prior degree = 25% ± 8%; n = 88; 95% CI = 23.4%–26.8%; t = 2.87; P = .005). Because a higher proportion of English-speaking residents had prior degrees, we adjusted the scores according to both language and the duration of the consultation. Even after adjustment, we continued to observe a significant difference in the OPTION scores of residents with a prior degree and residents without one (P < .05). We found no association between residents' age and the OPTION score (r = −0.16, P > .05) or between the score and the resident's participation in a committee or a work group (t = −0.13, P = .89) or participation in a continuing medical education activity over the prior year (t = −1.13, P = .26). Furthermore, there was no statistically significant difference between the resident's year of training and the OPTION score. The mean scores (±SD) were 24% (±7), 24% (±8), and 21% (±7) for first-, second-, and third-year residents, respectively (P = .26 after adjusting for the duration of the consultation). Finally, the analyses revealed no association between the preference of the patient about his or her role in decision making (see Table 2) and the OPTION score of the corresponding resident (r = −0.09, P = .29).
Our findings show that SDM behaviors are not widely or well integrated in the practice of family medicine residents in the context of this study. Although there is no consensus on optimal OPTION scores, a mean score of 24% suggests that further skill building is needed for family medicine residents to be better able to involve their patients in decision making. These scores are similar to those of other published studies that used the revised OPTION scale to assess the practice of SDM behaviors by fully licensed physicians working in diverse medical settings. We cannot associate these weak OPTION scores with patients' lack of motivation to be involved in decision making, because most patients desire to take part in the decision-making process.7
What do these scores teach us?
Our findings support the theory that the duration of the consultation is an important factor in residents' capacity to apply SDM behaviors. Nonetheless, the evidence suggests that professionals who have had SDM training can incorporate SDM behaviors without lengthening the consultation.36 It therefore seems likely that the low scores obtained in our study result from the participation of residents—that is, physicians who are not fully licensed—who had not been trained in SDM. This observation points to the merit of offering appropriate training and giving residents enough time at the beginning of their residency to learn to integrate SDM in their consultations. Giving residents specific tools such as patient decision aids, which are known to provide information that enables patients to more actively participate in treatment decisions,37 could also help residents practice SDM within the time normally allocated for a consultation.
Our analysis also allows us to determine which SDM behaviors measured by the OPTION scale residents most applied and which they least applied in their clinical practice. Of these behaviors, the three highest-ranked and the five lowest-ranked items are of particular interest. Although the OPTION scale is unidimensional, the three highest-ranked items are highly related in that they evaluate the resident's ability to deliver information appropriately by “drawing attention to an identified problem requiring a decision making process” (Item 1), “listing the options which can include the choice of ‘no action’” (Item 4), and “explaining the pros and cons of options” (Item 5). All three items target problems and treatments and focus on curing the patient and delivering information.38 Although curing must remain a main purpose of any consultation, the SDM philosophy emphasizes patient participation. Therefore, to promote patients' involvement in health decisions, efforts to encourage caring for the patient—as opposed to merely curing him or her—are needed.38 For example, the residency curricula could include seminars and simulated cases for residents to learn and practice these specific SDM behaviors.
The five lowest-ranked items obtained scores under 25%, which, according to OPTION classification, falls below “a minimal attempt is made to exhibit the behavior.” Caring is a key element in consultations, particularly insofar as it improves the resident's ability to “explore the patient's concerns (fears)” (Item 7). This item figured among the five lowest-ranking behaviors. The behavior “indicating the need for a decision making (or deferring) stage” (Item 11) also earned a low score. Although residents put a lot of energy into informing their patients, they rarely indicated to patients the need to make a decision. This omission helps explain patients' limited involvement in the final decision and may reflect residents' willingness to be transparent in their clinical approach but their reluctance to negotiate or deal with decisions taken by their patients. Also, our findings suggest that residents have difficulty “eliciting the patient's preferred level of involvement” (Item 10). Although some clinicians argue that they can identify their patients' preferred level of involvement without asking, research has emphasized that they cannot, in general, do so.39–44 Moreover, several studies have shown that patients' satisfaction and commitment to treatment are higher when the patient and the practitioner agree on the patient's role in the decision-making process, on the meaning of the diagnosis and the prognosis, and on the treatment plan.41,42,45,46
Another rarely observed SDM behavior was “stating that there is more than one way to deal with the problem” (Item 2). Making explicit the existence of more than one valid option helps the patient to understand that there is no absolute answer to his or her health problem and that each option needs to be considered. Stating that there is more than one way to deal with the problem can also encourage residents to balance the pros and the cons of each option. The least observed behavior was “assessing preferred approach to receiving information” (Item 3). The low score obtained for this element may be explained by the context. Considering the variety of medical conditions seen in primary care,47,48 residents might not have different formats of information—leaflets, videos, reviews—for every condition. If residents feel that they cannot offer patients a choice of format, they might consider it futile to assess the patient's preference of ways to receive information. This reality highlights the notion that primary care physicians are not well equipped to transfer knowledge to their patients—and, by extension, are not well equipped to facilitate SDM. Developing interventions like patient decision aids, whose effectiveness has been proven, could be a way to overcome this shortcoming.8
Overall, the low scores recorded in this study suggest the necessity of improving residents' ability to practice SDM in their encounters. The lack of patient-centered behaviors that we have documented here should be targeted by medical education programs to improve family medicine residents' ability to exhibit SDM behaviors and involve their patients in clinical encounters. The fact that SDM is not taught throughout the medical curriculum may explain these low scores, as may the fact that residents do not see SDM modeled in clinical practice. Better integration of SDM throughout the curriculum, combined with appropriate role models, would be beneficial. The medical formation could include specific training sessions on SDM such as large-group learning, directed independent learning, seminars/workshops, small-group sessions, simulation, patient care experiences, and longitudinal patient care experiences. Also, medical educators would need to be trained and tooled on risk communication. This study, like the Association of American Medical Colleges' “Recommendations for Preclerkship Clinical Skills Education For Undergraduate Medical Education,”49 offers a basis for developing SDM interventions throughout the medical curriculum.
Strengths and limitations
To the best of our knowledge, our study is the first to provide a basis for interventions that target the promotion of specific SDM behaviors among residents working in teaching units in primary care, an area known for its decisional diversity. Our study based its assessments on the OPTION scale, a validated scale assessing 12 SDM-specific behaviors, and benefitted from a substantial sample of 152 participating dyads recruited in two different parts of Canada (French- and English speaking). As such, it offers a broad perspective of Canadian medical residents' practice of SDM in primary care.
The study also has limitations. First, measuring a phenomenon as complex and subjective as the medical decision-making process can be influenced by a number of factors. Among them is a particularity of the scale. The OPTION scale is designed to measure clinicians' ability to involve patients in decision making; it does not take patients' participation into account. A patient could approach many of the elements contained in the OPTION grid proactively, thereby initiating the SDM process, but unless the clinician expressed 1 of the 12 behaviors measured—which, if the client were proactive enough, the clinician might not be called on to do—the scale would measure the clinician's exhibition of SDM behavior as nil. It is therefore possible that OPTION scores underestimate not only the resident's practice of SDM but also his or her potential or willingness to practice SDM. In this way, OPTION fails to reflect SDM's nature as a dynamic process that is influenced by the evolution of the interaction between the clinician and the patient.50
Second, because a previous study did not find an association between decisional conflict scores and the nature of the health care decision made,51 we assumed that any encounter could lead to SDM. For this reason, we did not code and stratify patients' reasons for consulting. However, Elwyn and colleagues28 have suggested that the type of consultation may influence patients' involvement and that in some cases, like follow-up encounters, SDM-specific behaviors may already have taken place. This could serve to underestimate a given resident's overall OPTION score and reduces our ability to draw associations between the type of consultation and the OPTION score.
Third, it remains possible that videotaping the consultations might have allowed the coders to identify additional behaviors. Our decision to not videotape may therefore also have underestimated the scores. At the same time, agreeing to participate in an SDM study and knowing the encounter to be audiotaped could lead residents to display more SDM behaviors than they otherwise would. This could mean that even the low scores observed in our studies were inflated. Moreover, we acknowledge that a unique dyad—in other words, a single encounter—do not accurately represent each resident's ability or indeed tendency to translate SDM in clinical practice, because some encounters may be less favorable to SDM than others.
Lastly, as mentioned earlier, this study only recruited family medicine residents in Canada. For that reason, its results cannot be judged as representative of family medicine residents in other countries. For all of these reasons, our findings must be interpreted with caution.
This descriptive study used a third-observer instrument to assess family medicine residents' adoption of SDM-specific behaviors in primary-care-related decisions. The findings should inform health service researchers and educators working to develop interventions targeting behaviors essential for SDM, particularly in the context of family medicine residencies. Special attention should be paid to the allocation of the time necessary for residents to perform SDM, on focusing on caring as well as on curing, on reinforcing the importance of engaging patients' participation in consultations, and on developing communication tools to be used by both the residents and their patients.
The authors greatly appreciate the contributions of the patients and physicians who participated in this study; of the recruitment team in London under the leadership of Moira Stewart (Christina Bodea and Sherry Benko); of the recruitment team in Quebec City (Anthony Calabrino, Marie-Laure Dioh, Hubert Robitaille, Marc-André Pellerin, Lilianne Bordeleau, Annie LeBlanc); and of the coders who rated the consultations with the OPTION scale (Véronique Couture, Sébastien Courchesne-O'Neill, Hubert Robitaille, Marc-André Pellerin). The authors thank Merlin Njoya for helping with statistical analyses and Jennifer Petrela for her role in editing the text. France Légaré holds a Tier 2 Canada Research Chair in the Implementation of Shared Decision Making in Primary Care.
This study is part of EXACKTE2: “Exploiting the clinical consultation as a knowledge transfer and exchange environment,” a project funded by the Canadian Institutes of Health Research (CIHR 2008–2011; grant #185649-KTE). The EXACKTE2 team is composed of France Légaré, Moira Stewart, Glyn Elwyn, Michel Rousseau, Michel Labrecque, Dawn Stacey, Dominick Frosch, Jeremy Grimshaw, Mathieu Ouimet, and Trudy van der Weijden.
Ethical approval for this study was granted by the research ethics board of the Centre de Santé et de Services Sociaux de la Vieille Capitale in Quebec City, Quebec, Canada (final approval 2008/11/25; ethics number #2008-2009-23) and the Office of the Research Ethics of the University of Western Ontario (final approval 2009/02/03; ethics number #15712E).
The authors presented a poster based on this research at the 32nd Annual Meeting of the Society for Medical Decision Making in Toronto, Ontario, Canada, October 23 to 27, 2010.
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