Purpose: Considerable scholarship has focused on physician communication skills for shared decision making, but little is known about why patients are sometimes reluctant to engage in a collaborative dialogue with physicians.
Method: An online panel of respondents (N=1,340; Mean age = 56.5, SD=9.9) read a vignette describing a treatment decision making scenario focused on moderate coronary artery disease. The vignette emphasized that three treatment options exist with equivalent long-term mortality outcomes. Respondents answered theory-based questions, building on Fishbein’s Integrative Model, focused on three key communication behaviors that facilitate shared decision making: (1) asking questions, (2) discussing preferences and (3) disagreeing with a recommendation. The first two are necessary for exchanging information. We asked about “disagreeing with a recommendation” as a potentially necessary assertive behavior if a physician’s recommendation is incongruent with patient preferences. Questions focused on respondents’ intention to engage in these behaviors in response to the scenario, their beliefs about the likely outcomes of doing so, and who would approve or disapprove of these actions. Data were analyzed with analysis of variance.
Result: Respondents had significantly lower intentions to disagree with a recommendation not congruent with their preferences (M=3.1, SD=1.5) than to ask questions (M=6.5, SD=.95) or discuss preferences (M=6.5, SD=.92; p<.0001). Intentions to disagree were highest among those indicating a preference for autonomous decision making (p<.0001). Intentions to ask questions (p<.003) and discuss preferences (p<.0001) were highest among those indicating a preference for shared decision making. Disagreeing was perceived as more likely to result in the physician viewing the patient as “difficult” (p<.0001), harming the therapeutic relationship (p<.0001), and lowering the likelihood of getting the “treatment that results in outcomes I prefer” (p<.0001). Respondents indicated that medical staff would be less likely to approve of asking questions (p<.0001), discussing preferences (p<.0001) or disagreeing with a physician (p<.0001) than spouses, family members or friends.
Conclusion: Results from this survey indicate that patients have little difficulty envisioning exchanging information with their physicians, but are much less likely to envision disagreeing with a preference incongruent recommendation. Paradoxically, respondents felt that disagreeing would lower the likelihood of getting their preferred treatment. Combined with the perception that medical staff are less supportive of active patient communication, these results provide evidence of considerable medical-cultural barriers to shared decision making.