PS 4-13
EVALUATING SHARED DECISION-MAKING IN TRIAL OF LABOR AFTER CESAREAN COUNSELING USING OBJECTIVE STRUCTURED CLINICAL EXAMINATIONS
Method: The case described a pregnant patient with a history of one prior vaginal delivery followed by a cesarean, presenting requesting TOLAC consultation. A trained standardized patient (SP) performed the case during the residents’ annual OSCE. Residents were provided with all clinical data needed to calculate the patient’s chance of successful TOLAC; and instructed to counsel the patient and develop a plan of care for her delivery. Encounters were directly observed, video- and audio-recorded. A 9-item measure of shared decision-making was adapted to a 10-item scoring rubric (risk and benefits of TOLAC were scored separately). Each item was rated as 0 (absent), 1 (partial), or 2 (complete). Three coders independently rated the encounters. Discrepancies were resolved by majority.
Result: Fifteen first-year residents; 9 second-years; and 10 third-years participated. All residents provided ‘complete’ discussions of the clinical issue/nature of the decision, and all received ‘complete’ or ‘partial’ ratings for efforts to assess the patient’s understanding. The majority of residents received ‘complete’ or ‘partial’ ratings for discussions of the patient’s chance of successful TOLAC (59% and 32%, respectively). Risks were more frequently discussed in terms of maternal risks as opposed to neonatal risks. With regards to neonatal risks, 85% of residents had ‘complete’ discussions of risks associated with TOLAC, but only 41% discussed neonatal risks associated with repeat cesarean. While the majority of encounters addressed at least one risk to mom or baby, discussions of benefits to mom and/or baby were typically absent. Almost half of the residents (47%) had no discussion of the patient’s goals/context for the decision; 50% lacked discussion of uncertainties related to the decision; and 44% failed to explore the patient’s preference—most deferring a ‘decision’ to a future encounter.
Conclusion: We developed an OSCE to evaluate SDM in OB/GYN residents’ TOLAC consultations. Residents consistently addressed discussions of diagnosis, prognosis, and maternal risk in their counseling; yet infrequently addressed maternal and neonatal benefits, uncertainties, or patients’ goals or preferences. This suggests that critical elements of SDM are absent and that interventions and training are needed for improvement.