Purpose: Patient values constitute a core element in definitions of evidence-based medicine and shared decision-making (SDM). The aim of this study was to explore type of, context in which and clinician’s response to patients’ treatment-related appraisals, i.e. patient utterances that reflect an evaluation of treatment aspects or alternatives.
Method: Two coders independently rated videotaped initial visits of 25 consecutive newly-diagnosed prostate cancer patients to one of nine radiation oncologists. Coders labeled appraisals (type) and utterances by patients, companions and clinicians (context and clinician’s response) occurring within 30 seconds before and after the appraisal using qualitative methodology. The Decision Analysis System for Oncology (Das-O) was used to assess SDM elements in clinicians’ behavior.
Result: With all patients a treatment decision was considered and in 76% of visits a decision was reached. Benefits and side effects of treatment alternatives were discussed in 59% and 85% of cases respectively. Patients uttered appraisals or agreed with companions Md=2±3 times per visit (range, 0–11, total number=63). Appraisals occurred mostly (93%) while discussing treatment options. Half of the appraisals referred to positive and 24% to negative evaluations of options or aspects thereof. One-fifth (19%) of appraisals referred to explicit tradeoffs between benefits and side effects within or between options. Appraisals mostly (62%) followed clinician information-giving. In 26% of cases, the clinician explicitly or implicitly enquired about patient’s treatment evaluation. Clinicians approved appraisals (38%); reacted neutrally to them (18%); repeated, briefly checked or reflected on them (12%); or explored them (3%). In 19% of cases, clinicians provided information contrary to appraisals, mostly (8/12) following a patient’s negative appraisal.
Conclusion: Patients appear to focus their attention more often on positive treatment aspects, including considering side effects as not problematic, than on negative aspects. More fully informing patients about options may help them weigh better the information and increase the number of appraisals they express. Clinicians most often legitimized patients’ appraisals. They less commonly helped patients further construct appraisals by exploring them. Approving appraisals may help patients to feel heard and taken seriously. Yet exploring patients’ appraisals may help patients in forming stable preferences regarding treatment options, which as a consequence may help clinicians and patients to select care that fits best the individual patient.
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