IS THERE LESS SHARED DECISION MAKING WHEN THE PROVIDER MAKES A RECOMMENDATION?

Purpose: Shared decision making requires a balanced presentation of treatment options, the benefits and risks of those options, and a discussion of patients’ preferences. However, when a provider makes a treatment recommendation, he or she may not give a balanced presentation of treatment options and may not seek the patient's input. Here, we compare patient reports of involvement in breast cancer surgery interactions when surgeons make a recommendation and when they do not.

Method: Women with early stage breast cancer eligible for mastectomy and lumpectomy were surveyed.  Patients reported whether the provider made a recommendation and if so what it was, and completed seven items about their interaction including (1) discussion of options (2) discussion of pros (3) discussion of cons, and (4) discussion of patients’ treatment preference. The interaction items were summed and scaled to a total involvement score (0-100%) with higher scores indicating more shared decision making. Our hypothesis was that when providers made a recommendation, they would be less likely to have balanced discussion or ask for patients’ preferences, and patients would report lower total involvement scores. We also examined individual items to determine whether there were differences in the specific aspects of the interaction.

Result: 440 patients completed the survey. Patients were on average 57 years old, white (83%), and the majority had a lumpectomy (62%). Most patients (85%) reported that their doctor made a recommendation for surgery.  The recommendations were mainly for lumpectomy and radiation (62%) followed by mastectomy (27%). The total involvement scores were similar for those who received a treatment recommendation (60%) and those who did not (63%) (p=0.08). Providers who did not make a recommendation were more likely to mention mastectomy as an option (80% vs. 66%, p=0.02) and were more likely to ask patients for their preferences (66% vs. 45%, p=0.01). There were no significant differences in discussion of lumpectomy or pros and cons of the options.

Conclusion: Contrary to our hypotheses, the overall level of involvement was fairly similar when providers made a recommendation and when they did not.  However, some behaviors did vary, as providers who did not make a recommendation were more likely to mention both treatment options and to ask patients for their preferences