'That's the doctor's job': Overcoming patient reluctance to be involved in medical decision making

Developing an implementation intervention, and identifying strategies for integrating health innovations in routine practice: A case study of the implementation of an insulin patient decision aid

BACKGROUND

Implementation, which is defined as the process of getting evidence-based innovation to be utilised is critical in ensuring innovation is being integrated into real-world practice. The way an implementation intervention (i.e., a bundle of strategies to facilitate implementation) is developed has an impact on the types of strategies chosen, and whether they are relevant to the implementation setting to exert their effects. However, literature pertaining to development of intervention or detailed descriptions of implementation processes are scarce. This study aims to report the development of an implementation intervention to integrate the use of an evidence-based innovation in routine practice, using a Malaysian insulin patient decision aid (PDA) as an exemplar.

METHODS

The development of the insulin PDA implementation intervention was divided into two phases, incorporating step 3 and 4 of the Action Cycle in the Knowledge to Action framework. In Phase 1, barriers to the insulin PDA implementation was explored through qualitative interviews using an interview guide developed based on the Theoretical Domains Framework. In Phase 2, prioritisation of the barriers was conducted using the multivoting technique. Next, potential strategies that can address the barriers were identified based on understanding the clinic context, and evidence from literature. Then, the selected strategies were operationalised by providing full descriptions in terms of its actor, action, action target, temporality, dose, implementation outcome affected, before they were embedded into the patient care pathway in the clinic. The implementation intervention was finalised through a clinic stakeholders meeting.

RESULTS

In Phase 1, a total of 15 focus group discussions and 37 in-depth individual interviews were conducted with: healthcare policymakers (n = 11), doctors (n = 22), diabetes educators (n = 8), staff nurses (n = 6), pharmacists (n = 6), and patients (n = 31). A total of 26 barriers and 11 facilitators emerged and they were categorised into HCP, patient, organisational, and innovation factors. The multivoting exercise resulted in the prioritisation of 13 barriers, and subsequently, a total of 11 strategies were identified to address those barriers. The strategies were mandate change, training workshop, involve patients' family members or caretakers, framing/reframing, inform healthcare providers on the advantages of the insulin PDA use, define roles and responsibilities, place the insulin PDA in the consultation room, provide feedback, systematic documentation, to engage patients in treatment discussions, and juxtapose PDA in preferred language with patient's PDA in their preferred language to help with translation.

CONCLUSION

This study highlights main barriers to PDA implementation, and strategies that can be adopted for implementation. The steps for intervention development in this study can be compared with other intervention development methods to advance the field of implementation of evidence-based innovations.

Palliative Care in Sub-Saharan Africa: A Narrative Review

Background: As a person nears the end of their life, culture and ethnicity increasingly drive preferences and priorities for care. Understanding these preferences and priorities is fundamental to health care professionals' goals to respect decision making and support the individual throughout this phase of life. Across Africa, several countries are in the initial stages of implementing palliative care services in their burgeoning health care systems. Moving forward, it is imperative to consider cultural similarities and differences when compared with the Western world, where the field of palliative care evolved, to create a tailored palliative care approach that is consistent with African culture. In palliative care, understanding cultural preferences and priorities requires communication between the patient and the provider and is a crucial step toward a successful implementation in Africa. A paternalistic patient-provider relationship is the current leading model in sub-Saharan Africa.1 Aim: This narrative review explores the prevalence of paternalism and explores its appropriateness and necessity in the current application of palliative care in sub-Saharan African countries. Methods: This narrative review was conducted using four databases as well as hand searching of relevant articles sourced from references of already selected articles. A total of 730 articles were identified. Fourteen articles met the inclusion/exclusion criteria set for this narrative review. Results: In sub-Saharan Africa, the leading patient-provider relationship was determined to be paternalistic. Reasons for this were language, education, cultural norms and expectations, lack of time, and benevolence. Conclusions: The implementation of palliative care often relies on communication of patient desires and goals. Consideration is needed to determine how a provider can appropriately know these factors in a paternalistic relationship.

Analysis of the Use of Sample Size and Effect Size Calculations in a Temporomandibular Disorders Randomised Controlled Trial-Short Narrative Review

BACKGROUND/OBJECTIVES

Temporomandibular disorder (TMD) is the term used to describe a pathology (dysfunction and pain) in the masticatory muscles and temporomandibular joint (TMJ). There is an apparent upward trend in the publication of dental research and a need to continually improve the quality of research. Therefore, this study was conducted to analyse the use of sample size and effect size calculations in a TMD randomised controlled trial.

METHODS

The period was restricted to the full 5 years, i.e., papers published in 2019, 2020, 2021, 2022, and 2023. The filter article type-"Randomized Controlled Trial" was used. The studies were graded on a two-level scale: 0-1. In the case of 1, sample size (SS) and effect size (ES) were calculated.

RESULTS

In the entire study sample, SS was used in 58% of studies, while ES was used in 15% of studies.

CONCLUSIONS

Quality should improve as research increases. One factor that influences quality is the level of statistics. SS and ES calculations provide a basis for understanding the results obtained by the authors. Access to formulas, online calculators and software facilitates these analyses. High-quality trials provide a solid foundation for medical progress, fostering the development of personalized therapies that provide more precise and effective treatment and increase patients' chances of recovery. Improving the quality of TMD research, and medical research in general, helps to increase public confidence in medical advances and raises the standard of patient care.

Perspectives of Community Nurses on Treatment Engagement of Persons with Severe Mental Illnesses (PwSMI): A Qualitative Study from South India

Background

There is increasing evidence of the need for treatment engagement between Persons with Severe Mental Illnesses (PwSMIs) and Mental Health Professionals (MHPs). This therapeutic process involves collaborative work between patients and MHPs, which improves the condition. Community nurses are uniquely positioned to facilitate this process as they act as the focal point of interaction between patients and the health system.

Methods

This qualitative study explored the community nurses' experiences in treatment engagement with PwSMI through eight group interviews of 35 community nurses from District Mental Health Programs (DMHPs) across Karnataka (South India) from February 2020 to March 2020. The audio recordings of the interviews were transcribed and coded to arrive at themes and subthemes.

Results

The major themes identified were factors influencing treatment engagement, strategies to tackle treatment nonengagement, and challenges in dealing with nonengagement. The reasons for nonengagement were lack of insight and lack of knowledge of sociocultural, logistic, and treatment-related factors. The DMHP teams contacted patients through phone calls, home visits, and liaisons with health workers and intervened with them through education and depot injections. The major challenges were difficulty conducting home visits, distances, the unavailability of medications, and the need for adequate infrastructure and human resources.

Conclusion

Community nurses address a few factors of nonengagement, such as insight, sociocultural factors, and treatment-related factors. Addressing the systemic challenges and adequate training of nurses in intervening in the dropped-out PwSMIs would help to reduce the treatment gap.

Recruiting general practitioners and older patients with multimorbidity to randomized trials

BACKGROUND

Older patients with multimorbidity are under-represented in experimental research.

OBJECTIVE

To explore the barriers and facilitators to general practitioner (GP) and older patient recruitment and retention in a cluster randomized controlled trial (RCT).

METHOD

This descriptive study uses qualitative and quantitative data from a cluster RCT, designed to evaluate the effectiveness of a medicines optimization intervention. The SPPiRE cluster RCT enrolled 51 general practices and 404 patients aged ≥65 years and prescribed ≥15 medicines. Quantitative data were collected from all recruited practices and 32 additional practices who were enrolled, but unable to recruit sufficient participants. Qualitative data were collected from purposive samples of intervention GPs (18/26), patients (27/208), and researcher logs and analysed thematically using inductive coding.

RESULTS

Enrolment rates for practices and patients were 37% and 25%, respectively. Barriers to GP recruitment were lack of resources and to patient recruitment were difficulty understanding trial material and concern about medicines being taken away. GPs' primary motivation was perceived importance of the research question, whereas patients' primary motivation was trust in their GP. All general practices were retained. Thirty-five patients (8.6%) were lost to follow-up for primary outcomes, mainly because they had died and 45% did not return patient-reported outcome measures (PROMs).

CONCLUSION

Patient retention for the primary outcome was high, as it was collected directly from patient records. Patient completion of PROM data was poor, reflecting difficulty in understanding trial material. Recruiting older patients with multimorbidity to clinical trials is possible but requires significant resource and planning.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN12752680.

Surgery patients' perspectives of their role in postoperative pain: A scoping review

Background

Post-operative pain is a major factor in surgical recovery. There is evidence that pain remains undermanaged. Complications related to the undermanagement of acute pain can increase length of stay and contribute to readmission and the development of chronic pain. It is well acknowledged that pain assessment is critical to pain management and that self-report of pain is the gold standard. As a result, patients play a central role in their own pain management. A preliminary review of the literature failed to provide a clear or consistent description of this key patient role.

Objective

A scoping review was conducted with the objective of reviewing literature that described adult patients' perspectives or highlighted the adult patient's role in post-operative pain management, including assessment. Understanding patients' attitudes toward their roles in pain management through a scoping review of the current literature is critical for informing research and improvements in post-operative pain management.

Design

Scoping review.

Methods

The databases searched for the review included CINAHL, MEDLINE, PubMed, and SCOPUS (ending May 2022). Thematic analysis, using the methodology of Arksey and O'Malley, was applied to the records identified.

Results

Of the 106 abstracts initially identified, 26 papers were included in the final analysis. Two major themes identified through thematic analysis were attitudes toward pain and pain management, with the subthemes of patient expectations and beliefs and desire to treat; and care and communication, with the subthemes of pain assessment and education.

Conclusions

This paper provides one of the first known comprehensive scoping reviews of surgical patients' perspectives of their role in pain management, including assessment, and offers an important global awareness of this patient role. The findings suggest that improved understanding of patients' perspectives of their roles in pain assessment and treatment is critical to improving post-operative pain management. Engaging patients as partners in their care can facilitate enhanced communication and improving congruence in pain assessment and treatment decisions. The complex nature of patients' beliefs, expectations, and subjective experiences of pain present challenges for health care practitioners. These challenges can be met with enhanced education for patients, respect for patients' beliefs and expectations, and the provision of dignified care.

Exploring Older Adult Health Literacy in the Day-to-Day Management of Polypharmacy and Making Decisions About Deprescribing: A Mixed Methods Study

BACKGROUND

Polypharmacy use in older adults is increasing and sometimes leads to poor health outcomes. The influence of health literacy in managing polypharmacy and making decisions about stopping medication has received limited attention.

OBJECTIVE

A mixed methods design was used to measure and investigate the influence of health literacy in the management of polypharmacy and decisions about deprescribing. Phase 1 involved two cross-sectional surveys, one with older adults using five or more medications and the other with general practitioners (GPs).

METHODS

Older adult health literacy was measured using the All Aspects of Health Literacy Scale. Phase 2 employed individual interviews with both older adults and GPs and further explored the reported use of health literacy in practice. SPSS version 24 was used to conduct descriptive statistical analysis of the Phase 1 survey responses and Phase 2 interviews were analyzed using thematic analysis with the assistance of NVivo 12.

KEY RESULTS

Phase 1 survey responses were received from 85 GPs and 137 older adults. Phase 2 interviews were conducted with 16 GPs and 25 older adults. Phase 1 results indicated that self-reported older adult health literacy was high, and that GPs believed older patients could engage in decisions about deprescribing. Phase 2 findings showed that older adults developed and employed complex health literacy practices to manage medications between consultations; however, few reported using their health literacy skills in consultations with their GPs. GPs noted that older adult involvement in decision-making varied and generally thought that older adults had low health literacy.

CONCLUSION

Older adults reported using health literacy practices in the management of their sometimes-complex medication regimens. However, the role of health literacy in deprescribing decision-making was limited. The mixed methods approach allowed greater insight into older adult and GP practices that influence the acquisition and use of health literacy. [HLRP: Health Literacy Research and Practice. 2023;7(1):e14-e25.] Plain Language Summary: This report explores health literacy in the use of multiple medications and decisions to stop using medication/s in older age. Older adults reported good heath literacy and practiced many health literacy skills in the management of their medications. However, they did not always report the use of their health literacy skills when discussing their medications with their family doctor.

Patient views on asthma diagnosis and how a clinical decision support system could help: A qualitative study

INTRODUCTION

Making a diagnosis of asthma can be challenging for clinicians and patients. A clinical decision support system (CDSS) for use in primary care including a patient-facing mode, could change how information is shared between patients and healthcare professionals and improve the diagnostic process.

METHODS

Participants diagnosed with asthma within the last 5 years were recruited from general practices across four UK regions. In-depth interviews were used to explore patient experiences relating to their asthma diagnosis and to understand how a CDSS could be used to improve the diagnostic process for patients. Interviews were audio recorded, transcribed verbatim and analysed using a thematic approach.

RESULTS

Seventeen participants (12 female) undertook interviews, including 14 individuals and 3 parents of children with asthma. Being diagnosed with asthma was generally considered an uncertain process. Participants felt a lack of consultation time and poor communication affected their understanding of asthma and what to expect. Had the nature of asthma and the steps required to make a diagnosis been explained more clearly, patients felt their understanding and engagement in asthma self-management could have been improved. Participants considered that a CDSS could provide resources to support the diagnostic process, prompt dialogue, aid understanding and support shared decision-making.

CONCLUSION

Undergoing an asthma diagnosis was uncertain for patients if their ideas and concerns were not addressed by clinicians and were influenced by a lack of consultation time and limitations in communication. An asthma diagnosis CDSS could provide structure and an interface to prompt dialogue, provide visuals about asthma to aid understanding and encourage patient involvement.

PATIENT AND PUBLIC CONTRIBUTION

Prespecified semistructured interview topic guides (young person and adult versions) were developed by the research team and piloted with members of the Asthma UK Centre for Applied Research Patient and Public Involvement (PPI) group. Findings were regularly discussed within the research group and with PPI colleagues to aid the interpretation of data.

Factors which influence the deprescribing decisions of community-living older adults and GPs in Australia

Deprescribing aims to reduce polypharmacy and inappropriate medication use. Both General Practitioners (GPs) and older adults have expressed a willingness to consider deprescribing. However, deprescribing is often deferred in practice. The aim of this study was to identify factors which influence GP and older adult decisions about deprescribing in primary care. Semi-structured interviews were used in this qualitative study, conducted in a regional area in Australia. Participants included GPs and adults aged 65 years or older, using five or more medications and living independently in the community. Data were collected between January 2018 and May 2019. Thematic analysis was used to analyse the verbatim transcribed interviews using NVivo 12. A total of 41 interviews were conducted, 25 with older adults and 16 with GPs. Four key themes influenced deprescribing decisions: views of ageing, shared decision-making, attitudes toward medication use and characteristics of the health care environment. Discussions of deprescribing were limited by the influence of negative stereotypes toward age and ageing, a lack of older adult participation in shared decision-making, a positive attitude towards ongoing medication use and perception of the normality of using medications in older age. Time constraints, poor communication about prescribing information and unclear roles regarding responsibility for deprescribing also prevented discussions. Continuity of care, involvement of older adults in medication reviews and GPs who asserted their generalist role were the main factors which promoted discussion of deprescribing. GPs are well placed to discuss deprescribing with their older patients because they are trusted and can provide continuity of care. Actively encouraging and involving older adults in medication reviews in order to understand their preferences, supports shared decision-making about deprescribing. Active involvement may also reduce the influence of negative views of ageing held by both older adults and GPs.

Motivating deprescribing conversations for patients with Alzheimer's disease and related dementias: a descriptive study

Introduction:

Older adults with Alzheimer’s disease and related dementias (ADRD) are at increased risk of harm due to prescribing of potentially inappropriate medications. Encouraging patients and caregivers to talk with their providers about potentially inappropriate medications could stimulate deprescribing. Our objective was to explore whether mailing educational materials to patients with ADRD might activate patients or caregivers to initiate a conversation with their provider about potentially inappropriate medications.

Methods:

We conducted semi-structured interviews with patients with ADRD, caregivers of patients with ADRD, and healthcare providers. All participants were shown educational materials referencing potentially inappropriate medications and suggestions to promote deprescribing. Interviews explored reactions to the materials, the idea of patients and caregivers initiating a conversation about deprescribing, and the deprescribing process. Interview transcripts were analyzed using inductive thematic analysis.

Results:

We conducted a total of 27 interviews: 9 with caregivers only, 2 with patients only, 3 with patient–caregiver dyads, and 13 with providers. Patients and caregivers reported that if a medication might cause harm, it would motivate them to talk to their provider about the medication. Trust in the provider could facilitate or inhibit such conversations; conversations would be more likely if there were prior positive experiences asking questions of the provider. Providers were receptive to patients and caregivers initiating conversations about their medications, as they valued deprescribing as part of their clinical practice and welcome informed patients and caregivers as participants in decision-making about medication.

Conclusion:

Mailing educational materials about potentially inappropriate medications to community-dwelling patients with ADRD may promote deprescribing conversations. Ongoing pragmatic trials will determine whether such interventions stimulate deprescribing conversations and achieve reductions in prescribing of inappropriate medications.

Plain Language Summary

Encouraging patients with Alzheimer’s disease to talk with their providers about medications that may cause harm

Introduction: Older adults with Alzheimer’s disease and related dementias (ADRD) are sometimes prescribed medications that may cause harm, especially when taken for extended periods of time. Patients and their caregivers may not know about the risks. Doctors know of the risks but may not address them due to competing priorities or other challenges in providing care to these patients with complex needs. Encouraging the patient or their caregiver to talk to their doctor about their medications might help to reduce the use of medications that are not beneficial. This study’s goal was to explore whether sending educational materials to patients with ADRD might encourage patients or caregivers to ask their doctor about their medications.

Methods: We interviewed patients with ADRD, caregivers, and doctors. We showed them educational materials that suggested patients and their caregivers talk to their doctor about reducing or stopping medications that may be harmful. We asked for reactions to the materials and to the idea of talking to the doctor about stopping the medication.

Results: We conducted 27 interviews: 9 with caregivers only, 2 with patients only, 3 with patient–caregiver dyads, and 12 with doctors. Patients and caregivers said learning that a medication might cause harm would motivate them to talk to their doctor about the medication. Trust in their doctor was important. Some patients and caregivers were comfortable asking questions about medications, while others were reluctant to challenge the doctor. Doctors were open to patients and caregivers asking about medications and felt it was important that patients not take medications that are not needed.

Conclusion: Sending educational materials to patients with ADRD and caregivers may encourage them to talk with their doctors about stopping or reducing medications. Studies are needed to learn whether such materials lead to reductions in prescribing of potential harmful medications.

Twelve Tips for teaching shared decision making

Shared decision making (SDM) is a process in which preference-sensitive decisions are discussed with patients in a collaborative and accessible format so that patients can select an option that integrates their values and preferences into the context of evidence-based medicine. While SDM has been shown to improve some metrics of quality of care and is now included in many competencies developed by accreditation bodies, it can be challenging to successfully incorporate competencies in SDM into clinical teaching. Multiple interventions and curricula that build competency in SDM have been published, but here we aim to suggest ways to integrate teaching competencies in SDM into all forms of clinical teaching. These twelve tips provide strategies to foster trainee development of the relational and risk-benefit communication competencies that are required for successful shared decision making.

Treatment decision making (TDM): a qualitative study exploring the perspectives of patients with chronic haematological cancers

OBJECTIVES

Haematological malignancies are the fifth most common cancer in the UK, with chronic subtypes comprising around a third of all new diagnoses. These complex diseases have some similarities with other cancers, but often require different management. Surgical resection is not possible, and while some are curable with intensive chemotherapy, most indolent subtypes are managed with non-aggressive intermittent or continuous treatment, often over many years. Little is known about the views of patients with chronic haematological cancers regarding treatment decision making (TDM), a deficit our study aimed to address.

SETTING AND DESIGN

Set within the Haematological Malignancy Research Network (HMRN: www.hmrn.org), an ongoing population-based cohort that provides infrastructure to support evidence-based research, HMRN data were augmented by qualitative information from in-depth interviews. Data were analysed for thematic content, combining inductive and deductive approaches. Interpretation involved seeking meaning, salience and connections within data.

PARTICIPANTS

Thirty-five patients with four chronic subtypes: chronic lymphocytic leukaemia, follicular lymphoma, marginal zone lymphoma, and myeloma. Ten relatives were present and contributed to varying extents.

RESULTS

Five themes were discerned: (1) Preference for clinician recommendations; (2) Factors implicated in patient involvement in TDM; (3) Perceptions of proactive/non-proactive approaches to TDM; (4) Experiences of TDM at various points in the disease trajectory; (5) Support from others. Our principal finding relates to a strong preference among interviewees for treatment recommendations from haematologists, based on trust in their expertise and perceptions of empathetic patient-clinician relationships.

CONCLUSION

Interviewees wanted to be involved in TDM to varying extents, contingent on complex, inter-related factors, that are dynamic and subject to change according to differing clinical and personal contexts. Patients may benefit from clinicians assessing their shifting preferences for involvement on multiple occasions. Strong preferences for acceptance of recommendations was associated with cancer complexity, trust in clinician expertise and positive perceptions of patient-clinician relationships.

Discussions on Present Japanese Psychocultural-Social Tendencies as Obstacles to Clinical Shared Decision-Making in Japan

In Japan, where a prominent gap exists in what is considered a patient’s best interest between the medical and patient sides, appropriate decision-making can be difficult to achieve. In Japanese clinical settings, decision-making is considered an act of choice-making from multiple potential options. With many ethical dilemmas still remaining, establishing an appropriate decision-making process is an urgent task in modern Japanese healthcare. This paper examines ethical issues related to shared decision-making (SDM) in clinical settings in modern Japan from the psychocultural-social perspective and discusses the ideal decision-making process in present Japan. Specifically, we discuss how five psychocultural-social tendencies – “surmise (Sontaku),” “self-restraint (Jishuku),” “air (atmosphere or mood, Kuuki),” “peer pressure (or tuning pressure, Docho-Atsuryoku),” and “community (Seken)”—which have often been referred to as characteristics of present-day Japanese people, may affect the ideal practice of SDM in Japanese clinical settings. We conclude that health care professionals must be aware of the possible adverse effects of the above Japanese psychocultural-social tendencies on the implementation of SDM and attempt to promote autonomous decision-making, thereby allowing patients to make treatment choices that sufficiently reflect their individual and personal views of life, experiences, goals, preferences, and values.

The development of incorpoRATE: A measure of physicians' willingness to incorporate shared decision making into practice

OBJECTIVES

To develop 'incorpoRATE', a brief and broadly applicable measure of physicians' willingness to incorporate shared decision making (SDM) into practice.

METHODS

incorpoRATE was developed across three phases: 1) A review of relevant literature to inform candidate domain and item development, 2) Cognitive interviews with US physicians to iteratively refine the measure, and 3) Pilot testing of the measure across a larger sample of US physicians to explore item and measure performance.

RESULTS

The final measure consists of seven items that assess physician perspectives on various components of SDM use that may present as barriers in practice. During pilot testing, the majority of physicians expressed positive opinions about the overall concept of SDM, yet were less comfortable acting on informed patient choices when there was known incongruence with their own recommendations.

CONCLUSIONS

incorpoRATE is a novel physician-reported measure that assesses physicians' willingness to incorporate SDM in practice.

PRACTICE IMPLICATIONS

incorpoRATE has the potential to help us further understand the limited adoption of SDM and areas of focus for improving the use of SDM in the future. We recommend that incorpoRATE be subject to further psychometric, real-world testing, in order to explore its performance across different samples of physicians and organizations.

Treatment Beliefs in Patients with Mental Disorders in Psychosomatic Rehabilitation

Abstract. Background: The efficacy of inpatient psychosomatic rehabilitation in Germany can be considered proven. However, a significant number of patients with mental disorders remain unsatisfied with rehabilitation or being non-responders. Illness beliefs, as the core element of the Common-Sense Model of Self-Regulation (CSM), are widely known as predictors of various health outcomes. Yet, little is known about treatment beliefs as an extension of the CSM and their impact on health outcomes. Aim: As treatment beliefs differ in relation to the treatment, this study aimed to explore rehabilitation-related treatment beliefs in psychosomatic rehabilitation patients with mental disorders before inpatient admission. Thus, knowledge of the concept of rehabilitation-related treatment beliefs will be added. Methods: N = 10 semi-structured telephone interviews were conducted in September/October 2018. A purposive sampling approach was chosen based on the criteria gender, age, and diagnosis. Participants were asked about their rehabilitation expectations starting with an open narrative question. Interviews were analyzed using qualitative content analysis. Results: Participants had a mean age of 48.3 years ( SD = 9.42); five participants were female and five male. 9 main themes with 32 subthemes as components of the rehabilitation-related treatment beliefs were identified: reasons for rehabilitation, conditions within the clinic, rehabilitation planning, organization of the rehabilitation, the content of the rehabilitation, results of the rehabilitation, concerns, expectations toward one’s behavior, and contact to other patients. Limitation: Our sample was too small to analyze the data for different subgroups. Conclusion: Results show that rehabilitation-related treatment beliefs are multidimensional, addressing different aspects of psychosomatic rehabilitation.

Shared decision-making and the nuances of clinical work: Concepts, barriers and opportunities for a dynamic model

BACKGROUND

Shared decision-making (SDM) is considered the "final stage" that completes the implementation of evidence-based medicine. Yet, it is also considered the most neglected stage. SDM shifts the epistemological authority of medical knowledge to one that deliberately includes patients' values and preferences. Although this redefines the work of the clinical encounter, it remains unclear what a shared decision is and how it is practiced.

AIM

The aim of this paper is to describe how healthcare professionals manoeuvre the nuances of decision-making that shape SDM. We identify barriers to SDM and collect strategies to help healthcare professionals think beyond existing solution pathways and overcome barriers to SDM.

METHODS

Semi-structured interviews were conducted with 68 healthcare professionals from psychiatry, internal medicine, intensive care medicine, obstetrics and orthopaedics and 15 patients.

RESULTS

This study found that healthcare professionals conceptualize SDM in different ways, which indicates a lack of consensus about its meaning. We identified five barriers that limit manoeuvring space for SDM and contest the feasibility of a uniform, normative SDM model. Three identified barriers: (a) "not all patients want new role," (b) "not all patients can adopt new role," and (c) "attitude," were linked to strategies focused on the knowledge, skills and attitudes of individual healthcare professionals. However, systemic barriers: (d) "prioritization of medical issues" and (e) "lack of time" render such individual-focused strategies insufficient.

CONCLUSION

There is a need for a more nuanced understanding of SDM as a "graded" framework that allows for flexibility in decision-making styles to accommodate patient's unique preferences and needs and to expand the manoeuvring space for decision-making. The strategies in this study show how our understanding of SDM as a process of multi-dyadic interactions that spatially exceed the consulting room offers new avenues to make SDM workable in contemporary medicine.

Perceived involvement in health care decisions among US adults: Sociodemographic and medical condition correlates

OBJECTIVE

To explore factors associated with how often US adults perceived that they were "always" involved in decisions about health care to the degree that they desired.

METHODS

We examined cross-sectional, nationally representative data from the 2018 Health Information National Trends Survey. There were 3504 responses in the full HINTS dataset; 2499 remained after eliminating respondents with missing data for any factor of interest. Sociodemographic factors included age, gender, race/ethnicity, and education. Medical conditions included diabetes, hypertension, heart disease, lung disease, arthritis, cancer, and depression. Participants were asked to think about communication with health professionals during the last 12 months and how often health professionals involved them in decisions about health care.

RESULTS

In univariate analyses, Asian and Hispanic race were associated with lower odds of always being involved in decisions about health care; whereas higher education and a history of cancer were associated with higher odds of "always" being involved in decisions about health care, p < 0.05. In multivariate analyses, race and education both remained significant; however, history of cancer did not.

CONCLUSION

Differences by race/ethnicity and educational attainment exist regarding perceived involvement in decisions about health care.

PRACTICE IMPLICATIONS

Findings may inform future shared decision making interventions.

Using Communication Theory of Identity to Evaluate Decision Aids: Focus Group Research with African American Prostate Cancer Survivors

Prostate cancer remains a significant health concern for U.S. adults, especially African American men, who have higher rates of diagnosis than other racial/ethnic groups. The current study evaluated five prostate cancer decision aids (PCDAs) focused on diagnosis and treatment via seven focus groups with 30 African American survivors. Consistent with the communication theory of identity, three layers of identity were salient in discussing PCDAs: personal, relational, and communal. African American men perceived existing PCDAs positively, evaluating them as accessible, efficacy inducing, and helpful in managing identity threats (personal layer of identity). Participants also found PCDAs to be central to decision making (relational layer of identity). Yet, there were concerns about the perceived lack of representation of African Americans in PCDAs (communal layers of identity). The findings suggest that PCDAs connect to personal and relational layers of identity but do not match expectations of communal identity.

"Nobody's Ever Told Me That:" Women's Experiences with Shared Decision-making when Accessing Contraception

Half of all pregnancies in the United States are unintended. Contraceptive methods are effective in reducing unintended pregnancy burden. The shared decision-making model serves as best practice when choosing among healthcare options, and may be appropriate when considering contraceptive options. This study examined women's experiences with shared decision-making in contraceptive use dynamics. Researchers analyzed 38 interviews with women of reproductive age (range: 19-50 years) living in South Carolina (May-November 2016). Researchers completed a constant comparative method of data analysis using HyperRESEARCH 3.7.3 to explore reproductive-aged women's contraceptive decision-making. Shared decision-making provided a conceptual framework for analysis. Gaps in contraceptive knowledge, especially method effectiveness, impacted participants' experiences with contraception. Although participants believed they had adequate information, findings suggest they may not be fully informed about existing contraceptive options. Participants wanted options; however, results indicated women may not be actively involved in choosing contraception. Nuanced beliefs about contraception demonstrated preferences for patient-provider communication within the broader context of reproductive health and individual lifestyle needs. Findings from this study offer theoretical and practical recommendations to guide shared decision-making during contraceptive consultations to empower women in making informed and lifestyle-appropriate contraceptive choices.

"Along for the Ride": A Qualitative Study Exploring Patient and Caregiver Perceptions of Decision Making in Cancer Care

Background. Shared decision making is a cornerstone of an informed consent process for cancer treatment, yet there are often many physician and patient-related barriers to participation in the process. Decisions in cancer care are often perceived as relating to a discrete, treatment decision event, yet there is evidence that decisions are longitudinal in nature and reflect a multifactorial experience. Objective. To explore patient and caregiver perceptions of the choices and decision-making opportunities within cancer care. Design. Qualitative in-depth interviews with 37 cancer patients and 7 caregivers carried out as part of an evaluation of a cancer center’s effort to improve patient experience. Results. Participants described decision making related to four distinct phases in complex cancer care, with physicians leading, and often limiting, decisions related to disease assessment and treatment options and access, and patients leading decisions related to physician selection. Though physicians led many decisions, patients had a moderating influence on treatment, such that if patients did not like options presented, they would reconsider their options and sometimes switch physicians. Patients had various strategies for dealing with uncertainty when faced with decisions, such as seeking additional information to make an informed choice or making a conscious choice to defer decision making to the physician. Limitations. Patients were sampled from one academic cancer center that serves a predominantly Caucasian, Asian, and Hispanic/Latino population and received complex treatment. Conclusion. Because of the complexity of cancer treatment, many patients felt as though they were a “passenger” in decision making about care and did not lead many of the decisions, though many patients trusted their doctors to make the best decisions and were comforted by their expertise.

A standardized patient education class as a vehicle to improving shared decision-making and increasing access to breast reconstruction

BACKGROUND

Shared decision-making is a key component of patient-centered care and has been shown to improve patient satisfaction and quality of life. Herein, we study the impact of a standardized patient education class for prospective breast reconstruction patients on clinic efficiency, access to care, and perception on shared decision-making.

METHODS

The number of new patient consultations per clinic, as well as average duration of the first individual clinic encounter, was compared before and after the introduction of a standardized education class given by the senior author to all new breast reconstruction patients. To evaluate patients' perception of shared decision-making, the 9-item Shared Decision-Making Questionnaire (SDM-Q9) and the Satisfaction with Information scale of the BREAST-Q Reconstruction Module were electronically distributed among the patients and compared between the two groups.

RESULTS

Introduction of the patient education class was associated with a significant reduction in the duration of new patient encounters compared to historic controls (31.8 min vs. 53.5 min, p < 0.01) along with permitting a 43% increase in new patient visits. No differences in self-perceived patient education and autonomy were seen between class participants and historic controls in the SDM-Q9 scores (p = 0.58) and BREAST-Q scores (p = 0.14).

CONCLUSION

The introducing a standardized patient education class translated into a significant reduction in the duration of individual new patient encounters, thereby increasing patient access to care, while maintaining high-quality standards of self-perceived patient education and shared decision-making.

Patient involvement in surgical care-Healthcare personnel views and behaviour regarding patient involvement

BACKGROUND

All professions in surgical care have a responsibility to include patients in their health care. By Swedish law, all care should be done in dialogue with the patient. The essential part of health care is the meeting between patient and healthcare professional. In the interaction, a decision can be made, and needs can be identified to a safer care. Previous studies on patient participation have focussed on patients' perspectives in surgical care, but there is a paucity of studies about the personnel's perspective of estimated patient involvement in surgical care.

AIM

The aim of this study was to identify and describe healthcare personnel's view and behaviour regarding patient involvement in surgical care.

METHOD

A quantitative study with various professions was conducted. A validated questionnaire was used, remaining questions grouped under following areas: patient involvement, acute phase, hospital time, discharge phase and questions on employment and workplace.

RESULTS

A total of 140 questionnaires were sent out to a surgical clinic in Sweden, and 102 questionnaires were answered. All professionals stated that clear information is an important part of patient involvement in surgical care. Statistically significant differences existed between the professions in the subscale information. Physicians rated their information higher than the Registered Nurses (p = 0.005) and the practical nurses did (p = 0.001). Hindrances to involving patients were lack of time and other priority tasks.

CONCLUSIONS

Professionals in surgical care graded information to be the most important thing for patient involvement. Participation in important decisions, including the possibility to express personal views and ask questions, is important factors for patient involvement. Barriers against patient involvement are lack of time and prioritisation of other work activities.

Shared decision making: Physicians' preferred role, usual role and their perception of its key components

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.

The Rhetoric of the 'Passive Patient' in Indian Medical Negligence Cases

In this paper, I examine the rhetoric employed by court judgements, with a particular emphasis on the narrative construct of the 'passive patient'. This construction advances and reinforces paternalistic values, which have scant regard for the patients' preferences, values, or choices within the legal context. Further, I critique the rhetoric employed and argue that the use of this rhetoric is the basis for a precedent that limits the understanding and respect of patients. Through this paper, I present the contemporary use of the 'passive patient' construct in the context of the Indian legal system and describe how such constructions have become a source of normative justification for legal reasoning that jeopardizes the patient's agency. I argue for the primacy of 'respect for persons' within Indian law and the need to treat each patient as a person who has agency, preferences, and values during clinical interactions. I conclude by suggesting that laws that adopt narratives that acknowledging the significance of patient engagement and the relevance of effective communication during clinical encounters would help cultivate a culture of patient-centred care, by moving beyond the rhetoric of 'passive patient' and the 'health/choice' dichotomy.

Glycemic control in type 2 diabetes: role of health literacy and shared decision-making

Background: Improving glycemic control requires that patients actively participate in decisions about how to best live with the disease and adapt to the realities of self-care. Limited health literacy (HL) is related to poorer health outcomes and may make it difficult for patients to participate in shared decision-making (SDM). As such, understanding the relationship between HL and SDM and its impact on diabetes control is an urgent issue. Methods: A cross-sectional survey was conducted among outpatients with type 2 diabetes in a regional teaching hospital. Purposive sampling was used to recruit eligible 372 patients via self-administered questionnaires. HbA1C values were obtained from each patient's laboratory assay. Results: Among the 372 participants, 50.4% of patients preferred physician decision-making, 39.3% preferred SDM, and 10.3% preferred patient decision-making. The physician explaining the illness in colloquial language, having adequate time for discussion, and encouragement from the healthcare provider were the major factors influencing patients' involvement in SDM. Interactive HL and critical HL had positive correlations with patients' perceived involvement in SDM. Educational attainment and HL were positively related. The HbA1C values for patient decision-making and physician decision-making were approximately 1.4 times and 1.24 times higher than those of SDM, respectively. Conclusion: SDM led to better glycemic control. HL increased patients' perceived involvement in SDM. Therefore, it is necessary to improve levels of HL based on the educational attainment of patients. Physicians explaining illness in colloquial language is the key factor in promoting patients' perceived involvement in SDM.

"What would you recommend doctor?"-Discourse analysis of a moment of dissonance when sharing decisions in clinical consultations

BACKGROUND

Proven benefits of Shared Decision Making (SDM) include improved patient knowledge, involvement and confidence in making decisions. Although widely advocated in policy, SDM is still not widely implemented in practice. A common patient-reported barrier is feeling that "doctor knows best"; thus, patients often defer decisions to the clinician.

OBJECTIVE

To examine the nature of the discourse when patients ask clinicians for a treatment recommendation during consultations when treatment decisions are being shared and to examine clinicians' strategies used in response.

DESIGN, SETTING AND PARTICIPANTS

Theme-orientated discourse analysis was performed on eight audio-recordings of breast cancer diagnostic consultations in which patients or their partners attempted to defer treatment decisions to the clinician. Clinicians were trained in SDM.

RESULTS

Tension was evident in a number of consultations when treatment recommendations were requested. Clinicians responded to recommendation requests by explaining why the decision was being shared (personal nature of the decision, individual preferences and equivalent survival outcomes of treatment options). There was only one instance where a clinician gave a treatment recommendation.

DISCUSSION AND CONCLUSIONS

Strategies for clinicians to facilitate SDM when patients seem to defer decisional responsibility include being clear about why the decision is being shared, acknowledging that this is difficult and making patients feel supported. When patients seek guidance, clinicians can provide a recommendation if grounded in an understanding of the patient's values.

Parent engagement in autism-related care: a qualitative grounded theory study

Parents of children with autism assume substantial responsibility for navigating intervention to address autism-related concerns, including involvement in therapy. Little is known, from the perspective of these parents, regarding how to best engage and support them in this navigating process as it evolves over the child's development. In this article, we present findings from a large qualitative study that investigated how parents of children with autism navigate intervention, to construct an in-depth theoretical account of how this group comes to be engaged in individual-level care. Using grounded theory methods and a symbolic interactionist framework, we analyzed select documents and 45 intensive interviews conducted with 32 mothers and 9 expert professionals from urban and rural regions of Ontario, Canada. Parent-defined concerns are the central impetus for the core process of navigating intervention, labeled using parents' language making your own way. We describe how this process is analogous to engaging in care. Four meaning-making processes - defining concerns, informing the self, seeing what is involved, and adapting emotionally - all interacting in an ongoing fashion, together account for parents' evolving readiness and motivation for taking action to navigate intervention. We illustrate how parents' readiness and motivation for navigating intervention (and thus for engagement) evolves over a generalized trajectory, according to three highly overlapping processes experienced by most parents: coming to understand their child has autism, going into high gear, and easing off. These findings indicate multiple empirical conditions and factors affecting engagement that service planners and professionals will likely want to consider when seeking parent involvement as a means to improve outcomes in autism. Additionally, theoretical aspects are relevant to the developing understanding of how healthcare consumers in general become engaged in individual care, with implications for patient-centered care.

People with lived experience (PWLE) of depression: describing and reflecting on an explicit patient engagement process within depression research priority setting in Alberta, Canada

PLAIN ENGLISH SUMMARY

The Alberta Depression Research Priority Setting Project aimed to meaningfully involve patients, families and clinicians in determining a research agenda aligned to the needs of Albertans who have experienced depression. The project was modeled after a process developed in the UK by the James Lind Alliance and adapted to fit the Alberta, Canada context. This study describes the processes used to ensure the voices of people with lived experience of depression were integrated throughout the project stages. The year long project culminated with a facilitated session to identify the top essential areas of depression research focus. People with lived experience were engaged as part of the project's Steering Committee, as survey participants and as workshop participants. It is hoped this process will guide future priority setting opportunities and advance depression research in Alberta.

ABSTRACT

Background The Depression Research Priority Setting (DRPS) project has the clear aim of describing the patient engagement process used to identify depression research priorities and to reflect on the successes of this engagement approach, positive impacts and opportunities for improvement. To help support patient-oriented depression research priority setting in Alberta, the Patient Engagement (PE) Platform of the Alberta Strategy for Patient Oriented Research Support for People and Patient-Oriented Research and Trials (SUPPORT) Unit designed, along with the support of their partners in addictions and mental health, an explit process to engage patients in the design and execution of the DRPS. Methods The UK's James Lind Alliance (JLA) Priority Setting Partnership (PSP) method was adapted into a six step process to ensure voices of "people with lived experience" (PWLE) with depression were included throughout the project stages. This study uses an explicit and parallel patient engagement process throughout each estage of the PSP designed by the PE Platform. Patient engagement was divided into a five step process: i) Awareness and relationship building; ii) Co-designing and co-developing a shared decision making process; iii) Collaborative communication; iv) Collective sensemaking; and v) Acknowledgement, celebration and recognition. A formative evaluation of the six PE processes was undertaken to explore the success of the parallel patient engagement process. Results This project was successful in engaging people with lived depression experience as partners in research priority setting, incorporating their voices into the discussions and decisions that led to the top 25 depression research questions. Conclusions The DRPS project has positively contributed to depression research in Canada by identifying the priorities of Albertans who have experienced depression for depression research. Dissemination activities to promote further knowledge exchange of prioritized research questions, with emphasis on the importance of process in engaging the voices of PWLE of depression are planned.

Patients and caregivers' unmet information needs in the field of patient education: results from an Italian multicenter exploratory survey

Patient education and empowerment (PEE) is aimed at improving competence of patients during their clinical path and enabling healthcare providers with specific communication strategies. We investigated the interest of Italian Cancer Research & Care Centers (CRCI) users (patients and caregivers) in being involved in PEE activities. An anonymous questionnaire addressed to users was distributed between June 2013 and February 2014. The questionnaire gathered information on the following: health-related topics; 13 different PEE initiatives/modalities of learning already active at CRCI; personal demographic data; the willingness to be more involved in the organization of health services provided and in which context; and five preferred info-educational activities. Frequency distribution and chi-square analysis were computed. Statistical significance (p value) was set at < 0.05. A total of 875 (29%) users responded to the 3000 distributed questionnaires. The first three priorities of interest were “early diagnosis” (18%), “prevention” (17%), and “diagnosis explanation” (13%). The first three priorities on informational activity were as follows: “classes on cancer-related topics with healthcare professionals” (28%); “cancer information service” (22%); “drug information point” (7%). Forty-nine percent of the respondents stated that they would like to be involved in the organization of PEE activities, particularly caregivers and users older than 55 years of age. The preferred educational activities were “classes on cancer-related topics with healthcare professionals” and “cancer information service” on a face-to-face modality. Patients were more interested than caregivers in “prevention.” The extension of PEE programs to all CRCI users into routine care will be the next step of the present research.

How healthcare professionals experience patient participation in designing healthcare services and products. A qualitative study in the field of spinal cord injury in Switzerland

OBJECTIVES

This study explored healthcare professionals' accounts of patient participation, focusing particularly on aspects related to patients' contributions to the planning and design of healthcare services and products. It aimed to determine (1) how healthcare professionals experience patient participation, (2) what factors, in their view, may inhibit or promote it; and (3) through what channels they think it can take place.

METHODS

This study adopted a pragmatic epistemological approach. Data was collected through semi-structured interviews with healthcare professionals at four specialized centers for spinal cord injury in Switzerland.

RESULTS

Healthcare professionals who participated in this study were generally open to patient participation in the healthcare innovation process, highlighting several factors that may influence this process. Participants referred to three types of patient contributions that would usually emerge from informal exchange: (1) bringing in information unknown to staff; (2) reporting problems; and (3) providing concrete suggestions for improvement.

CONCLUSION & PRACTICE IMPLICATIONS

Healthcare professionals' positive view on and experiences with patient participation in the healthcare innovation process provide a fertile ground to further explore ways of fostering this new form of collaboration. Ultimately, it will be important to demonstrate its positive impact on both patients' as well as healthcare professionals' experiences.

Patient priorities and the doorknob phenomenon in primary care: Can technology improve disclosure of patient stressors?

OBJECTIVE

Patients with multiple chronic conditions face many stressors (e.g. financial, safety, transportation stressors) that are rarely prioritized for discussion with the primary care provider (PCP). In this pilot randomized controlled trial we examined the effects of a novel technology-based intervention called Customized Care on stressor disclosure.

METHODS

The main outcomes were stressor disclosure, patient confidence and activation, as assessed by self-report and observational methods (transcribed and coded audio-recordings of the office visit).

RESULTS

Sixty patients were enrolled. Compared with care as usual, intervention patients were 6 times more likely to disclose stressors to the PCP (OR=6.16, 95% CI [1.53, 24.81], p=0.011) and reported greater stressor disclosure confidence (exp[B]=1.06, 95% CI [1.01, 1.12], p=0.028). No differences were found in patient activation or the length of the office visit.

CONCLUSION

Customized Care improved the likelihood of stressor disclosure without affecting the length of the PCP visit.

PRACTICE IMPLICATIONS

Brief technology-based interventions, like Customized Care could be made available through patient portals, or on smart phones, to prime patient-PCP discussion about difficult subjects, thereby improving the patient experience and efficiency of the visit.

Elderly patients' and GPs' perspectives of patient-GP communication concerning polypharmacy: a qualitative interview study

AimThe aim of this study was to explore elderly patients' and general practitioners' (GPs') perceptions of communication about polypharmacy, medication safety and approaches for empowerment.

BACKGROUND

To manage polypharmacy, GPs need to know patients' real medication consumption. However, previous research has shown that patients do not always volunteer all information about their medication regimen, for example, such as the intake of over-the-counter medication or the alteration or discontinuation of prescribed medication.

METHOD

A qualitative interview study including patients of at least 65 years old with polypharmacy (⩾5 medications) and their GPs in a German Primary Healthcare Centre. The transcripts from the semi-structured interviews (n=6 with patients; n=3 with GPs) were analysed using a framework analytical approach.FindingsWe identified three themes: differing medication plans: causes?; dialogue concerning medication: whose responsibility?; supporting patients' engagement: how? While GPs stated that patients do not always report or might even conceal information, all patients reported that they could speak openly about everything with their GPs. In this context, trust might act as a double-edged sword, as it can promote open communication but also prevent patients from asking questions. Both GPs and patients could name very few ways in which patients could be supported to become more informed and active in communication concerning polypharmacy and medication safety.

CONCLUSION

This study shows that patients' awareness of the significance of their active role in addressing polypharmacy needs to be increased. This includes understanding that trusting the doctor does not preclude asking questions or seeking more information. Thus, interventions which improve patients' communication skills and address specific issues of polypharmacy, particularly in elderly patients, should be designed. GPs might support patients by 'inviting' their contribution.

Can we trust what parents tell us? A systematic review

Taking a history is a key diagnostic instrument in paediatric consultations. Numerous issues potentially reduce the history's reliability. Therefore, paediatricians have always expressed ambivalence regarding history taking from parents, both valuing and distrusting it. In this review, we describe how parents build and present a description of their child's health issues in the conceptual framework of self-regulation theory. We performed a systematic review on the literature on the reliability of history taking. No studies examined the reliability of history taking from parents, but there is a considerable body of evidence on the issue of mutual trust in relationships between health care professionals and patients. Because trust is a dynamic relational phenomenon, taking a patient centred approach in consultations is likely to increase the patients' and parents' trust in the health care professional, and their willingness to follow the health care professional's treatment proposals. We provide evidence based recommendations on how to build and maintain trust in paediatric consultations by taking a patient centred approach in such consultations.

What to do when a patient wants to record a patient-physician interaction in the emergency department

Recent technological advances allow for instantaneous high quality video and audio recordings with the touch of a button. In Canada, patient privacy is highly regulated by provincial legislation, although patients themselves have little in the way of laws or regulations to observe. Patients taking video recordings of their own medical care does not currently fall under any of the provincial privacy laws. With no such governance for the general public, patients generally have greater freedom to record a patient-physician interaction. Unfortunately, there are no official policies from the provincial physician colleges regarding how best to proceed in these circumstances. Therefore, the onus is on individual hospitals and emergency departments (EDs) to develop their own policy on video recordings. A policy should ideally cover possible recording devices, locations, staff involved, and mandate that a written consent form be included with the patient's chart. While every request should be considered individually, physicians should generally not feel compelled to agree to the patient recording the clinical encounter. Patients are legally allowed to record a patient-physician interaction without consent of their physician, because the patient can provide the "one-party consent" for the conversation to be recorded. Physicians should accept the possibility that they are being recorded at all times and should strive to communicate as clearly and effectively as possible. Physicians should strive to provide the same level of care that they would even if they were not being recorded, and not let it interfere with their clinical decision-making.