PATIENT'S SALIENT BELIEFS ABOUT COMMUNICATING AND MAKING DECISIONS WITH PHYSICIANS

Purpose: Considerable research in shared medical decision making has evaluated methods for providing information to patients and understanding how decision support interventions impact subsequent decision-making. Far less research has focused on the communication behaviors necessary for shared decision making, especially from the patient’s point of view.  Theory-based measurement instruments for these behaviors are lacking.

Method: We conducted a qualitative focus group study to identify patients’ salient beliefs about communicating with physicians in the context of preferences sensitive decisions. Building on the theoretical foundation of Fishbein’s Integrative Model of Behavior, we elicited primary care patients’ salient beliefs underlying attitudes, perceived social norms and self-efficacy related to asking questions, expressing preferences and disagreeing with a physician. Salient beliefs underlying attitudes reflect outcome expectancies associated with engaging in the behavior of interest. Normative beliefs reflect who respondents believe would approve or disapprove of them engaging in the behavior. Efficacy beliefs reflect the circumstances that individuals believe would enable or hinder engaging in the behavior. Participants (N=48) were recruited from primary care practices from the Palo Alto Medical Foundation and were at least 40 years old (Mean = 64.7, SD = 12.1).

Results: Participants identified a range of salient beliefs. Outcome expectancies included both positive and negative consequences resulting from communicating with a physician. Potential beneficial outcomes included building a partnership with the physician, understanding how treatment options might affect the patient, getting one’s preferred treatment, and making an informed decision. Potential negative outcomes included being viewed as a difficult patient, harming the doctor-patient relationship and being overwhelmed by too much information. Individuals who might approve or disapprove of engaging in these communication behaviors included spouse, family members, friends, medical staff and the physician.  Circumstances that were identified as potential barriers to communicating were the physician being in a hurry, not being treated with respect, being afraid of the answer one might receive and having a serious condition.

Conclusion: The salient beliefs identified in this study highlight the importance of the doctor-patient relationship in facilitating shared decision-making and on the other hand suggest that patients are concerned about negative future consequences that could result from taking an active role in decision-making. These salient beliefs provide the basis for developing a theory-based measure of determinants of shared decision-making communication behaviors.