A SYSTEMATIC REVIEW OF PHYSICIANS' STATED ATTITUDES TOWARD SHARED DECISION-MAKING

Purpose: To determine (1) the stated attitudes and opinions of physicians regarding the use of shared decision making (SDM) in clinical practice, and (2) to explore variation in such attitudes relating to decision scenarios and/or clinical specialties.

Methods: A systematic review of recent literature (2009 to present), with searches of Medline, Embase, Cochrane Database of RCTs, CINAHL and PsychInfo using keywords and MeSH terms. Title and abstract screening, full text review, and data abstraction was conducted independently and in duplicate, with disagreements resolved by a third reviewer. Heterogeneity in study methods necessitated informal quality assessment and precluded formal meta-analysis.

Results: The search produced 4356 references. Following abstract and title screening, 28 papers were selected, with only 14 subsequently included following full text review. Inter-rater agreement was very high (Cohen’s kappa: 0.86). Our findings suggest generally positive physician attitudes toward SDM in clinical practice but there is considerable variation. Decision scenarios where physicians tended to be supportive of SDM include severe or chronic illness, prevention-related decisions and decisions with multiple therapeutic options. Variation in support for SDM was driven in part by patient characteristics (i.e. competency and willingness to participate in the decision making process). Support for SDM also varied by clinical specialty with, for example, oncologists, psychiatrists and gynecologists expressing more favourable attitudes in general. Process considerations relating to SDM were also explored in some studies; for example, physicians varied in their preference regarding who should make the final treatment decision within an SDM consultation (i.e., physician or patient). Varying definitions and conceptualizations for SDM can be seen across the literature and this may impact how SDM is understood and applied in clinical scenarios.

Conclusions: Although evidence suggests that SDM can improve patient outcomes, and is preferred by many patients, uptake to date has been sparse. Previous research has focused predominantly on patients’ attitudes. Although physicians’ responses may be susceptible to social desirability bias, in terms of physician’s expressed attitudes, our review suggests that physicians are supportive of SDM, but levels of support differ across clinical specialties. This may not be surprising as those specialties that deal with preference sensitive decisions are intuitively more likely to support the adoption of an SDM framework.