DEVELOPMENT OF A TOOL FOR IDENTIFICATION AND CLASSIFICATION OF DECISIONS IN MEDICAL ENCOUNTERS

Purpose: Despite increasing attention to the field of shared decision making, the medical literature provides little support and no tool to identify and classify decisions in patient-physician encounters. Addressing this void we are developing a typology to provide support in exploring links between the quality of clinical communication and medical decisions.

Method: A combination of qualitative methods has been used to study a selection of 130 available videotaped encounters from the Department of Internal Medicine in a Norwegian general hospital. The material from 7 subspecialities consist of 95 encounters from outpatient clinics, 25 from rounds and 10 from the emergency room. The initial use of grounded theoretical approach to identify and categorize clinical decisions has been supplemented by iterative group discussions with physicians and researchers in clinical communication.

Result: There are distinct differences in decision-making observed in the outpatient clinic, on rounds and in the emergency room. Dividing consultations into three phases; information gathering, problem defining, and management phase seems to be a feasible approach for all clinical situations. Decisions observed share properties resulting in possible subdivisions within each phase.  Also decision-making relates to past, present and future tense differently and is observed as conveyance of past conclusions, revelation of present decisions and discussion concerning future needs and possible outcomes. All these deliberate acts of communication contribute to the process where the patient´s provided care and the physician´s application of skills are products.  We find great variety in nature, complexity and importance of clinical decisions. As our aim is to establish associations between communication behaviour and quality of decisions it is evident that some decision types, e.g. drug-related, diagnostic, follow up decisions, are more relevant to assess than others. The classification system covering all kinds of decisions we have observed will be presented in detail.

Conclusion: We are developing a new tool that can be used to identify and classify medical decisions in clinical encounters. The typology opens up for a new mapping of the decision-making terrain and may be used in research on associations between different types of decisions, ambient communication and clinical outcomes.