IDENTIFICATION, CLASSIFICATION AND DISTRIBUTION OF CLINICAL DECISIONS IN 380 HOSPITAL ENCOUNTERS

Purpose: Previous studies quantifying clinical decisions in medical encounters have focused on patient involvement in decision-making and report an average of between three and four decisions per encounter. Hypothesizing that medical encounters contain a larger body of clinically relevant decisions, we aimed to identify and classify all signs of clinical decisions as they emerged as communicative actions in patient-physician encounters. 

Method: Building on previous work by Braddock et al, we developed The Decision Identification and Classification Typology for Use in Medicine (DICTUM) through a content driven iterative process informed by the experiences and perspectives of four doctors. The material comprised 380 videotapes with 59 doctors from eight specialties and three different settings (emergency room, ward round and outpatient clinic) in a Norwegian general hospital. Average duration of the encounters was 22 minutes.

Result: A decision in the context of a medical encounter was defined as “a verbal statement committing to a particular course of clinically relevant action and/or a statement concerning the patient’s health carrying meaning and weight because it is said by a medical expert”. In 243 coded encounters we found an average of 14 clinical decisions communicated per encounter, distributed across 10 topical categories; 29% defining problem, 17% evaluating test, 13% drug-related, 10% ordering test, 10% contact-related, 8% advice and precaution, 4% intervention, 4% deferment, 2% legally related, 1% treatment goal.  4-coder inter-rater reliability using Krippendorf’s alpha was 0,79. The total body of 380 videos will be coded and analyzed before SMDM 2014. Preliminary analyses indicate that there are significant differences in how decisions are communicated related to settings, specialties and physician experience.

Conclusion: DICTUM makes it possible to identify all clinically relevant decisions in videotaped patient-physician encounters. The average number of decisions identified with DICTUM is four times higher than in studies focusing on and measuring patient involvement in decisions. We argue that identifying the true decisional content of each clinical encounter is a potentially fruitful step in the process of making both providers and patients aware of opportunities for patient involvement in decision-making.