PARTNERING OR PERSUADING: DECISION MAKING DURING CONSULTATIONS BETWEEN BREAST CANCER PATIENTS AND MEDICAL ONCOLOGISTS

Purpose: Shared decision-making is widely advocated. However, oncologists frequently make adjuvant systemic treatment decisions unilaterally. A variety of implicit persuasive techniques are used to ensure agreement with the clinicians' recommendation. The aim of this study was to assess if, which, and how often medical oncologists use such (implicit) persuasion during consultations with early-stage breast cancer patients. We also assessed if there was a difference in use of persuasion techniques between chemotherapy and endocrine therapy decisions.

Methods: We audiotaped consecutive chemotherapy and endocrine therapy decision consultations in five hospitals. The audio was transcribed and independently coded by two researchers using a coding scheme adapted after the persuasive techniques described by Karnieli-Miller et al. Discrepancies in coding were resolved in consensus meetings.

Results:

Coding and analysis is on-going. The currently analyzed data for 66 patients, (median age 59 years; range 37-81) are summarized in Table 1. A median of four (range: 1-9) persuasive techniques was used in these consultations. The most frequently used techniques were presenting treatment as an authorized “we” decision (65%) and presenting the side-effects after the final treatment decision has been made (64%). For example, when deciding on endocrine therapy, in 66% of consultations patients were told that they could always choose to stop with the treatment if they had too many side-effects, however, the decision to start treatment was made unilaterally beforehand by the (team of) oncologists. In 91% of endocrine therapy decisions, the oncologist downplayed the impact of treatment: “it's just a small pill a day” or “aspirin has side effects too”.

Conclusions: Oncologists, wittingly or unwittingly, frequently employ techniques to steer patients towards the treatment option that they think is best. These techniques are used in both chemotherapy and endocrine therapy decision consultations, but which therapy is used varies. Even if they intend to share the decision to start or not to start treatment with patients, employing these tactics undermines this intent. Subtle and often well-intentioned, comforting utterances could strongly influence patients' decisions. Insight in such potentially disruptive mechanisms at play during actual decision-making processes can help overcome the performance gap between advocating and implementing shared decision-making.