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Mulder-Vos I, Driever EM, Brand PLP. Observational study on the timing and method of interruption by hospital consultants during the opening statement in outpatient consultations. BMJ Open 2023; 13:e066678. [PMID: 37770276 PMCID: PMC10546126 DOI: 10.1136/bmjopen-2022-066678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/04/2023] [Indexed: 09/30/2023] Open
Abstract
OBJECTIVE To analyse verbal interruptions by Dutch hospital consultants during the patient's opening statement in medical encounters. DESIGN Cross-sectional descriptive study. SETTING Isala teaching hospital in Zwolle, the Netherlands. PARTICIPANTS 94 consultations by 27 consultants, video recorded in 2018 and 2019. MAIN OUTCOME MEASURES Physicians' verbal interruptions during patients' opening statements, rate of completion of patients' opening statements, time to first interruption and the effect of gender, age and physician specialty on the rate and type of physicians' verbal interruptions. RESULTS Patients were interrupted a median of 9 times per minute during their opening statement, the median time to the first interruption was 6.5 s. Most interruptions (67%) were backchannels (such as 'hm hm' or 'go on'), considered to be encouraging the patient to continue. In 52 consultations (55%), patients could not finish their opening statement due to a floor changing interruption by the consultant. The median time to such an interruption was 31.4 s, on average 20 s shorter than a finished opening statement (p=0.004). Female consultants used more backchannels (median 9, IQR 5-12) than male consultants (median 7, IQR 2-11, p=0.028). CONCLUSIONS Hospital-based consultants use various ways to interrupt patients during their opening statements. Most of these interruptions are encouraging backchannels. Still, consultants change the conversational floor in more than half of their patients during their opening statements after a median of 31 s.
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Affiliation(s)
- Inge Mulder-Vos
- Isala Academy, Department of Medical Education and Faculty Development, Isala Hospital, Zwolle, The Netherlands
| | - Ellen M Driever
- Innovation and Research, Isala Hospital, Zwolle, The Netherlands
| | - Paul L P Brand
- Isala Academy, Department of Medical Education and Faculty Development, Isala Hospital, Zwolle, The Netherlands
- Wenckebach Institute for Medical Education and Faculty Development, University Medical Centre Groningen, Groningen, The Netherlands
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Driever EM, Stiggelbout AM, Brand PLP. Shared Decision-making in Different Types of Decisions in Medical Specialist Consultations. J Gen Intern Med 2022; 37:2966-2972. [PMID: 35037173 PMCID: PMC9485336 DOI: 10.1007/s11606-021-07221-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 10/15/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUNDS Research on shared decision-making (SDM) has mainly focused on decisions about treatment (e.g., medication or surgical procedures). Little is known about the decision-making process for the numerous other decisions in consultations. OBJECTIVES We assessed to what extent patients are actively involved in different decision types in medical specialist consultations and to what extent this was affected by medical specialist, patient, and consultation characteristics. DESIGN Analysis of video-recorded encounters between medical specialists and patients at a large teaching hospital in the Netherlands. PARTICIPANTS Forty-one medical specialists (28 male) from 18 specialties, and 781 patients. MAIN MEASURE Two independent raters classified decisions in the consultations in decision type (main or other) and decision category (diagnostic tests, treatment, follow-up, or other advice) and assessed the decision-making behavior for each decision using the Observing Patient Involvement (OPTION)5 instrument, ranging from 0 (no SDM) to 100 (optimal SDM). Scheduled and realized consultation duration were recorded. KEY RESULT In the 727 consultations, the mean (SD) OPTION5 score for the main decision was higher (16.8 (17.1)) than that for the other decisions (5.4 (9.0), p < 0.001). The main decision OPTION5 scores for treatment decisions (n = 535, 19.2 (17.3)) were higher than those for decisions about diagnostic tests (n = 108, 14.6 (16.8)) or follow-up (n = 84, 3.8 (8.1), p < 0.001). This difference remained significant in multilevel analyses. Longer consultation duration was the only other factor significantly associated with higher OPTION5 scores (p < 0.001). CONCLUSION Most of the limited patient involvement was observed in main decisions (versus others) and in treatment decisions (versus diagnostic, follow-up, and advice). SDM was associated with longer consultations. Physicians' SDM training should help clinicians to tailor promotion of patient involvement in different types of decisions. Physicians and policy makers should allow sufficient consultation time to support the application of SDM in clinical practice.
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Affiliation(s)
- Ellen M Driever
- Department of Innovation and Research, Isala Hospital, Dokter van Heesweg 2, 8025 AB, Zwolle, the Netherlands.
- Lifelong Learning Education and Assessment Research Network (LEARN), University Medical Center Groningen, Groningen, the Netherlands.
| | - Anne M Stiggelbout
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Paul L P Brand
- Lifelong Learning Education and Assessment Research Network (LEARN), University Medical Center Groningen, Groningen, the Netherlands
- Department of Medical Education and Faculty Development, Isala Hospital, Zwolle, the Netherlands
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Driever EM, Stiggelbout AM, Brand PLP. Patients' preferred and perceived decision-making roles, and observed patient involvement in videotaped encounters with medical specialists. Patient Educ Couns 2022; 105:2702-2707. [PMID: 35428525 DOI: 10.1016/j.pec.2022.03.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 03/14/2022] [Accepted: 03/27/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To assess how patients prefer and perceive medical decision making, which factors are associated with their preferred and perceived decision-making roles, and whether observed involvement reflects patients' perceived role. METHODS We asked 781 patients visiting a medical specialist from 18 different disciplines to indicate their preferred and perceived decision-making roles. Patient involvement in videotaped consultations was assessed with the OPTION5 instrument. RESULTS Most patients preferred and perceived decision making as shared (SDM; 58% and 43%, respectively), followed by paternalistic (26% and 38%), and informative (16% and 15%). A large minority (n = 103, 21%) of patients preferring shared or informative decision making (n = 482) experienced paternalistic decision making. Mean (SD) OPTION5 scores were highest in consultations which patients perceived as informative (26.0 (19.7)), followed by shared (19.1 (17.2)) and lowest in paternalistic decision making (11.8 (13.4) p < 0.001). CONCLUSIONS Most patients want to be involved in decision making. Patients perceive that the physician makes the decision more often than they prefer, and perceive more involvement in the decision than objective assessment by an independent researcher shows. PRACTICE IMPLICATIONS A clearer understanding of patients' medical decision-making experiences is needed to optimize physician SDM training programmes and patient awareness campaigns.
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Affiliation(s)
- Ellen M Driever
- Department of Innovation and Research, Isala Hospital, Zwolle, The Netherlands; Lifelong Learning Education and Assessment Research Netwerk (LEARN), University Medical Center Groningen, Groningen, The Netherlands.
| | - Anne M Stiggelbout
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Paul L P Brand
- Lifelong Learning Education and Assessment Research Netwerk (LEARN), University Medical Center Groningen, Groningen, The Netherlands; Department of Medical Education and Faculty Development, Isala Hospital, Zwolle, The Netherlands
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Siebinga VY, Driever EM, Stiggelbout AM, Brand PLP. Shared decision making, patient-centered communication and patient satisfaction - A cross-sectional analysis. Patient Educ Couns 2022; 105:2145-2150. [PMID: 35337712 DOI: 10.1016/j.pec.2022.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 03/12/2022] [Accepted: 03/15/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES The integration of shared decision making (SDM) and patient-centered communication (PCC) is needed to actively involve patients in decision making. This study examined the relationship between shared decision making and patient-centered communication. METHODS In 82 videotaped hospital outpatient consultations by 41 medical specialists from 18 disciplines, we assessed the extent of shared decision making by the OPTION5 score and patient-centered communication by the Four Habits Coding Scheme (4HCS), and analyzed the occurrence of a high versus low degree (above or below median) of SDM and/or PCC, and its relation to patient satisfaction scores. RESULTS In comparison to earlier studies, we observed comparable 4HCS scores and relatively low OPTION5 scores. The correlation between the two was weak (r = 0.29, p = 0.009). In 38% of consultations, we observed a combination of high SDM and low PCC scores or vice versa. The combination of a high SDM and high PCC, which was observed in 23% of consultations, was associated with significantly higher patient satisfaction scores. CONCLUSION Shared decision making and patient-centered communication are not synonymous and do not always co-exist. PRACTICE IMPLICATIONS The value of integrated training of shared decision making and patient-centered communication should be further explored.
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Affiliation(s)
- Veerle Y Siebinga
- Department of Innovation and Research, Isala Hospital, Zwolle, The Netherlands.
| | - Ellen M Driever
- Department of Innovation and Research, Isala Hospital, Zwolle, The Netherlands
| | - Anne M Stiggelbout
- Department of Medical Decision Making/ Quality of Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Paul L P Brand
- Department of Innovation and Research, Isala Hospital, Zwolle, The Netherlands; UMCG Postgraduate School of Medicine, University Medical Center, University of Groningen, The Netherlands
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Driever EM, Tolhuizen IM, Duvivier RJ, Stiggelbout AM, Brand PLP. Why do medical residents prefer paternalistic decision making? An interview study. BMC Med Educ 2022; 22:155. [PMID: 35260146 PMCID: PMC8903731 DOI: 10.1186/s12909-022-03203-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 01/19/2022] [Indexed: 05/19/2023]
Abstract
BACKGROUND Although shared decision making is championed as the preferred model for patient care by patient organizations, researchers and medical professionals, its application in daily practice remains limited. We previously showed that residents more often prefer paternalistic decision making than their supervisors. Because both the views of residents on the decision-making process in medical consultations and the reasons for their 'paternalism preference' are unknown, this study explored residents' views on the decision-making process in medical encounters and the factors affecting it. METHODS We interviewed 12 residents from various specialties at a large Dutch teaching hospital in 2019-2020, exploring how they involved patients in decisions. All participating residents provided written informed consent. Data analysis occurred concurrently with data collection in an iterative process informing adaptations to the interview topic guide when deemed necessary. Constant comparative analysis was used to develop themes. We ceased data collection when information sufficiency was achieved. RESULTS Participants described how active engagement of patients in discussing options and decision making was influenced by contextual factors (patient characteristics, logistical factors such as available time, and supervisors' recommendations) and by limitations in their medical and shared decision-making knowledge. The residents' decision-making behavior appeared strongly affected by their conviction that they are responsible for arriving at the correct diagnosis and providing the best evidence-based treatment. They described shared decision making as the process of patients consenting with physician-recommended treatment or patients choosing their preferred option when no best evidence-based option was available. CONCLUSIONS Residents' decision making appears to be affected by contextual factors, their medical knowledge, their knowledge about SDM, and by their beliefs and convictions about their professional responsibilities as a doctor, ensuring that patients receive the best possible evidence-based treatment. They confuse SDM with acquiring informed consent with the physician's treatment recommendations and with letting patients decide which treatment they prefer in case no evidence based guideline recommendation is available. Teaching SDM to residents should not only include skills training, but also target residents' perceptions and convictions regarding their role in the decision-making process in consultations.
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Affiliation(s)
- Ellen M Driever
- Department of Innovation and Research, Isala Hospital, Dokter van Heesweg 2, 8025, AB, Zwolle, the Netherlands.
- Lifelong Learning Education and Assessment Research Network (LEARN), University Medical Centre Groningen, Groningen, the Netherlands.
| | - Ivo M Tolhuizen
- Faculty of Medical Science, University Medical Centre of Groningen, Groningen, the Netherlands
| | - Robbert J Duvivier
- Centre for Education Development and Research in Health Professions (CEDAR), University Medical Centre Groningen, Groningen, the Netherlands
- Parnassia Psychiatric Institute, The Hague, the Netherlands
| | - Anne M Stiggelbout
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Centre, Leiden, the Netherlands
| | - Paul L P Brand
- Lifelong Learning Education and Assessment Research Network (LEARN), University Medical Centre Groningen, Groningen, the Netherlands
- Department of Medical Education and Faculty Development, Isala Hospital, Zwolle, the Netherlands
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Abstract
OBJECTIVES To assess whether consultants do what they say they do in reaching decisions with their patients. DESIGN Cross-sectional analysis of hospital outpatient encounters, comparing consultants' self-reported usual decision-making style to their actual observed decision-making behaviour in video-recorded encounters. SETTING Large secondary care teaching hospital in the Netherlands. PARTICIPANTS 41 consultants from 18 disciplines and 781 patients. PRIMARY AND SECONDARY OUTCOME MEASURE With the Control Preference Scale, the self-reported usual decision-making style was assessed (paternalistic, informative or shared decision making). Two independent raters assessed decision-making behaviour for each decision using the Observing Patient Involvement (OPTION)5 instrument ranging from 0 (no shared decision making (SDM)) to 100 (optimal SDM). RESULTS Consultants reported their usual decision-making style as informative (n=11), shared (n=16) and paternalistic (n=14). Overall, patient involvement was low, with mean (SD) OPTION5 scores of 16.8 (17.1). In an unadjusted multilevel analysis, the reported usual decision-making style was not related to the OPTION5 score (p>0.156). After adjusting for patient, consultant and consultation characteristics, higher OPTION5 scores were only significantly related to the category of decisions (treatment vs the other categories) and to longer consultation duration (p<0.001). CONCLUSIONS The limited patient involvement that we observed was not associated with the consultants' self-reported usual decision-making style. Consultants appear to be unconsciously incompetent in shared decision making. This can hinder the transfer of this crucial communication skill to students and junior doctors.
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Affiliation(s)
- Ellen M Driever
- Innovation and Research, Isala Hospitals, Zwolle, The Netherlands
| | - Anne M Stiggelbout
- Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Paul L P Brand
- Princess Amalia Children's Centre, Isala Klinieken, Zwolle, The Netherlands
- UMCG Postgraduate School of Medicine, University Medical Centre, Groningen, The Netherlands
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Driever EM, Brand PL. Education makes people take their medication: myth or maxim? Breathe (Sheff) 2020; 16:190338. [PMID: 32194770 PMCID: PMC7078734 DOI: 10.1183/20734735.0338-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Education on its own doesn't make people take their treatment as intended. However, when it follows shared decision making, in which patient and doctor together agree on the best course of therapeutic action, education helps patients take their treatment. http://bit.ly/2G2XswD.
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Affiliation(s)
- Ellen M. Driever
- Dept of Innovation and Science, Isala Hospital, Zwolle, The Netherlands
| | - Paul L.P. Brand
- Dept of Medical Education and Faculty Development, Isala Hospital, Zwolle, The Netherlands
- LEARN network, University of Groningen and University Medical Centre, Groningen, The Netherlands
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Driever EM, Stiggelbout AM, Brand PLP. Shared decision making: Physicians' preferred role, usual role and their perception of its key components. Patient Educ Couns 2020; 103:77-82. [PMID: 31431308 DOI: 10.1016/j.pec.2019.08.004] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 06/18/2019] [Accepted: 08/02/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To investigate physicians' preferred and usual roles in decision making in medical consultations, and their perception of shared decision making (SDM). METHODS A cross-sectional survey of 785 physicians in a large Dutch general teaching hospital was undertaken in June 2018, assessing their preferred and usual decision making roles (Control Preference Scale), and their view on SDM key components (SDMQ9 questionnaire). RESULTS Most physicians (n = 232, 58%) preferred SDM, but more often performed paternalistic decision making (n = 121, 31%) in daily practice than they preferred (n = 80, 20%, p < 0.0001), most commonly because they judged the patient to be incapable of participating in decision making. Most physicians preferring SDM presented different options for treatment (n = 213, 92%) with their advantages and disadvantages (n = 209, 90%) but fewer made clear that a decision had to be made (n = 104, 45%) or explored the patient's wish how to be involved in decision making (n = 80, 34%). CONCLUSION Although most physicians prefer SDM, they often revert to a paternalistic approach and tend to limit SDM to discussing treatment options. PRACTICE IMPLICATION Teaching physicians in SDM should include raising awareness about discussing the decision process itself and help physicians to counter their tendency to revert to paternalistic decision making in daily practice.
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Affiliation(s)
- Ellen M Driever
- Department of Innovation and Research, Isala Hospital, Zwolle, the Netherlands.
| | - Anne M Stiggelbout
- Department of medical Decision Making/ Quality of Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Paul L P Brand
- Department of Innovation and Research, Isala Hospital, Zwolle, the Netherlands; UMCG Postgraduate School of Medicine, University Medical Center, University of Groningen, the Netherlands
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Kerner GSMA, van Dullemen LFA, Wiegman EM, Widder J, Blokzijl E, Driever EM, van Putten JWG, Liesker JJW, Renkema TEJ, Pieterman RM, Mertens MJF, Hiltermann TJN, Groen HJM. Concurrent gemcitabine and 3D radiotherapy in patients with stage III unresectable non-small cell lung cancer. Radiat Oncol 2014; 9:190. [PMID: 25174943 PMCID: PMC4262382 DOI: 10.1186/1748-717x-9-190] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Accepted: 08/16/2014] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Stage III unresectable non-small cell lung cancer (NSCLC) is preferably treated with concurrent schedules of chemoradiotherapy, but none is clearly superior Gemcitabine is a radiosensitizing cytotoxic drug that has been studied in phase 1 and 2 studies in this setting. The aim of this study was to describe outcome and toxicity of low-dose weekly gemcitabine combined with concurrent 3-dimensional conformal radiotherapy (3D-CRT). PATIENTS & METHODS Treatment consisted of two cycles of a cisplatin and gemcitabine followed by weekly gemcitabine 300 mg/m2 during 5 weeks of 3D-CRT, 60 Gy in 5 weeks (hypofractionated-accelerated). Overall survival (OS), progression-free survival (PFS), and treatment related toxicity according to Common Toxicity Criteria of Adverse Events (CTCAE) version 3.0 were assessed. RESULTS Between February 2002 and August 2008, 318 patients were treated. Median age was 64 years (range 36-86); 72% were male, WHO PS 0/1/2 was 44/53/3%. Median PFS was 15.5 months (95% confidence interval [CI], 12.9-18.1) and median OS was 24.6 months (95% CI., 21.0-28.1). Main toxicity (CTCAE grade ≥3) was dysphagia (12.6%), esophagitis (9.6%), followed by radiation pneumonitis (3.0%). There were five treatment related deaths (1.6%), two due to esophagitis and three due to radiation pneumonitis. CONCLUSION Concurrent low-dose gemcitabine and 3D-CRT provides a comparable survival and toxicity profile to other available treatment schemes for unresectable stage III.
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Affiliation(s)
- Gerald S M A Kerner
- University of Groningen and Department of Pulmonary Diseases, University Medical Center Groningen, Hanzeplein 1, P,O, Box 30,001, Groningen 9700 RB, The Netherlands.
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