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      Delivering patient choice in clinical practice: a conversation analytic study of communication practices used in neurology clinics to involve patients in decision-making

      1 , 2 , 3 , 4 , 5
      Health Services and Delivery Research
      National Institute for Health Research

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          Abstract

          Background

          The NHS is committed to offering patients more choice. Yet even within the NHS, the meaning of patient choice ranges from legal ‘rights to choose’ to the ambition of establishing clinical practice as a ‘partnership’ between doctor and patient. In the absence of detailed guidance, we focused on precisely howto engage patients in decision-making.

          Objectives

          To contribute to the evidence-base about whether or not, and how, patient choice is implemented to identify the most effective communication practices for facilitating patient choice.

          Design

          We used conversation analysis to examine practices whereby neurologists offer choice. The main data set consists of audio- and video-recorded consultations. Patients completed pre- and post-consultation questionnaires and neurologists completed the latter.

          Setting and participants

          The study was conducted in neurology outpatient clinics in Glasgow and Sheffield. Fourteen neurologists, 223 patients and 120 accompanying others took part.

          Results

          Patients and clinicians agreed that choice had featured in 53.6% of consultations and that choice was absent in 14.3%. After 32.1% of consultations, eitherpatient orneurologist thought choice was offered. The presence or absence of choice was not satisfactorily explained by quantitatively explored clinical or demographic variables. For our qualitative analysis, the corpus was divided into four subsets: (1) patient and clinician agree that choice was present; (2) patient and clinician agree that choice was absent; (3) patient ‘yes’, clinician ‘no’; and (4) patient ‘no’, clinician ‘yes’. Comparison of all subsets showed that ‘option-listing’ was the only practice for offering choice that was present only(with one exception, which, as we show, proves the rule) in those consultations for which participants agreed there was a choice. We show how option-listing can be used to engage patients in decision-making, but also how very small changes in the machinery of option-listing [for instance the replacement or displacement of the final component of this practice, the patient view elicitor (PVE)] can significantly alter the slot for patient participation. In fact, a slightly modified form of option-listing can be used to curtail choice. Finally, we describe two forms of PVE that can be used to hand a single-option decision to the patient, but which, we show, can raise difficulties for patient choice.

          Conclusions

          Choice features in the majority of recorded consultations. If doctors want to ensure a patient knows she or he has a choice, option-listing is likely to be best understood by patients as an invitation to choose. However, an important lesson from this study is that simply asking doctors to adopt a practice (like option-listing) will not automatically lead to a patient-centred approach. Our study shows that precisely howa practice is implemented is crucial.

          Future research

          Future research should investigate (1) links between the practices identified here and relevant outcome measures (like adherence); (2) whether being given a choice is better or worse for patients than receiving a doctor’s recommendation, taking account of clinical and demographic factors; and (3) how our approach could be fruitfully applied in other settings.

          Funding

          The National Institute for Health Research Health Services and Delivery Research programme.

          Related collections

          Most cited references68

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          An integrative model of shared decision making in medical encounters.

          Given the fluidity with which the term shared decision making (SDM) is used in teaching, assessment and research, we conducted a focused and systematic review of articles that specifically address SDM to determine the range of conceptual definitions. In April 2005, we ran a Pubmed (Medline) search to identify articles published through 31 December 2003 with the words shared decision making in the title or abstract. The search yielded 681 citations, 342 of which were about SDM in the context of physician-patient encounters and published in English. We read and reviewed the full text of all 342 articles, and got any non-redundant references to SDM, which yielded an additional 76 articles. Of the 418 articles examined, 161 (38.5%) had a conceptual definition of SDM. We identified 31 separate concepts used to explicate SDM, but only "patient values/preferences" (67.1%) and "options" (50.9%) appeared in more than half the 161 definitions. Relatively few articles explicitly recognized and integrated previous work. Our review reveals that there is no shared definition of SDM. We propose a definition that integrates the extant literature base and outlines essential elements that must be present for patients and providers to engage in the process of SDM. The integrative definition of SDM is intended to provide a useful foundation for describing and operationalizing SDM in further research.
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            Confirming Allusions: Toward an Empirical Account of Action

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              Grammar and Social Organization: Yes/No Interrogatives and the Structure of Responding

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                Author and article information

                Journal
                Health Services and Delivery Research
                National Institute for Health Research
                2050-4349
                2050-4357
                March 2015
                March 2015
                : 3
                : 7
                : 1-170
                Affiliations
                [1 ]Academic Neurology Unit, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
                [2 ]Department of Sociology, University of York, Heslington, York, UK
                [3 ]Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
                [4 ]Department of Neurology, Southern General Hospital, Glasgow, UK
                [5 ]Department of Neurology, Christchurch Hospital, New Zealand
                Article
                10.3310/hsdr03070
                421dd562-5c2d-4326-a013-3156ba463c24
                © 2015
                History

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