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

Family medicine residents' perspectives on shared decision-making: A mixed methods study

OBJECTIVES

To 1) examine the willingness of residents to undertake shared decision-making and 2) explore whether the willingness to engage in shared decision-making is influenced by the perceived stakes of a clinical situation.

METHODS

Sequential mixed methods design. Phase One: Family Medicine residents completed IncorpoRATE, a seven-item measure of clinician willingness to engage in shared decision making. Mean IncorpoRATE scores were calculated. Phase Two: We interviewed residents from phase one to explore their perceptions of high versus low stakes situations. Transcripts were analyzed using qualitative content analysis.

RESULTS

IncorpoRATE scores indicated a greater willingness to engage in shared decision-making when the stakes of the decision were perceived as low (7.59 [2.0]) compared to high (4.38 [2.5]). Interviews revealed that residents held variable views of the stakes of similar clinical decisions.

CONCLUSION

Residents are more willing to engage in shared decision-making when the stakes of the situation are perceived to be low. However, the interpretation of the stakes of clinical situations varies.

PRACTICAL IMPLICATIONS

Further research is needed to explore how shared decision making is understood by residents in Family Medicine and when they view the process of shared decision-making to be most appropriate.

Perceptions of shared decision making in gastroenterology and inflammatory bowel disease: A qualitative analysis

OBJECTIVE

Shared decision-making (SDM) is the partnership and discussion between clinicians and patients to make an appropriate decision based on scientific evidence and patient preferences. Many benefits are associated with SDM; however, little is known about its awareness or use by inflammatory bowel disease (IBD) clinicians in gastroenterology departments across Israel. This study aims to identify barriers and facilitators in implementing SDM as standard practice to achieve optimal disease management and personalized care for patients with IBD.

METHODS

Sixteen semi-structured interviews were conducted with IBD clinicians across Israel to identify the barriers and facilitators for SDM use. An interview guide was developed, based on the systematic approach of the Theoretical Domain Framework (TDF). Interview transcripts were coded into theoretical domains to identify factors that may impact SDM.

RESULTS

Sixteen gastroenterologists from nine different hospitals were interviewed. Common TDF domains that presented as barriers were: knowledge, skills, social/professional role and identity, environmental context and resources, and reinforcement. Most participants had never heard the precise term "shared decision making" and lacked formal training on SDM.

CONCLUSION

This study identified key barriers and facilitators to SDM in IBD clinics across Israel. Main barriers of SDM include limited or nonexistent training; clinicians were unaware of SDM guidelines or techniques. The main facilitators of SDM were clinicians' social and professional role and identity and their beliefs about the influence of IBD and/or CD.

PRACTICE IMPLICATIONS

These influencing factors and TDF domains identified provide a basis for developing future interventions to improve the implementation of SDM within IBD management.

Prognostication and Goals of Care Decisions in Severe Traumatic Brain Injury: A Survey of The Seattle International Severe Traumatic Brain Injury Consensus Conference Working Group

Abstract Best practice guidelines have advanced severe traumatic brain injury (TBI) care; however, there is little that currently informs goals of care decisions and processes despite their importance and frequency. Panelists from the Seattle International severe traumatic Brain Injury Consensus Conference (SIBICC) participated in a survey consisting of 24 questions. Questions queried use of prognostic calculators, variability in and responsibility for goals of care decisions, and acceptability of neurological outcomes, as well as putative means of improving decisions that might limit care. A total of 97.6% of the 42 SIBICC panelists completed the survey. Responses to most questions were highly variable. Overall, panelists reported infrequent use of prognostic calculators, and observed variability in patient prognostication and goals of care decisions. They felt that it would be beneficial for physicians to improve consensus on what constitutes an acceptable neurological outcome as well as what chance of achieving that outcome is acceptable. Panelists felt that the public should help to define what constitutes a good outcome and expressed some support for a "nihilism guard." More than 50% of panelists felt that if it was certain to be permanent, a vegetative state or lower severe disability would justify a withdrawal of care decision, whereas 15% felt that upper severe disability justified such a decision. Whether conceptualizing an ideal or existing prognostic calculator to predict death or an unacceptable outcome, on average a 64-69% chance of a poor outcome was felt to justify treatment withdrawal. These results demonstrate important variability in goals of care decision making and a desire to reduce this variability. Our panel of recognized TBI experts opined on the neurological outcomes and chances of those outcomes that might prompt consideration of care withdrawal; however, imprecision of prognostication and existing prognostication tools is a significant impediment to standardizing the approach to care-limiting decisions.

A prospective study of shared decision-making in brain tumor surgery

PURPOSE

Shared decision-making (SDM) is a key tenet of personalized care and is becoming an essential component of informed consent in an increasing number of countries. The aim of this study is to analyze patient and healthcare staff satisfaction with the SDM process before and after SDM was officially introduced as the standard of care. Decision grids are important tools in the SDM process, and we developed them for three different types of intracranial tumors.

METHODS

This prospective study was conducted in a high-volume neuro-oncological center on all consecutive eligible patients undergoing consideration of treatment for intracranial glioma and metastases. Twenty-two patients participated before and 74 after the introduction of SDM. Six and 5 staff members respectively participated in the analysis before and after team training and the introduction of SDM. The main outcome was patient and healthcare staff satisfaction with the SDM process.

RESULTS

Patients reported high satisfaction with the SDM process before (mean CollaboRATE score 26 of 27 points) and after (mean CollaboRATE score 26.3 of 27 points, p = 0.23) the introduction of SDM. Interestingly, staff attitude toward SDM improved significantly from 61.68 before to 90.95% after the introduction of SDM (p-value < 0.001). Decision grids that were developed for three different types of intracranial tumors are presented.

CONCLUSIONS

Team training in SDM and the introduction of techniques into daily practice can increase staff satisfaction with the SDM process. High levels of patient satisfaction were observed before, with a non-significant increase after the introduction of SDM. Decision grids are an important tool to facilitate the conveyance and understanding of complex information and to achieve SDM in daily clinical practice.

Using incorpoRATE to examine clinician willingness to engage in shared decision making: A study of Family Medicine residents

OBJECTIVES

We evaluated the willingness of Family Medicine residents to engage in SDM, before and after an educational intervention.

METHODS

We delivered a lecture and a workshop for residents on implementing SDM in preventive health care. Before the lecture (T1), participants completed a measure of their willingness to engage in SDM. Six months later, participants completed the measure a second time (T2).

RESULTS

At T1, 64 of 73 residents who attended the educational session completed incorpoRATE. Six months later, 44 of 64 participants completed the measure a second time (T2). The range of incorpoRATE sum scores at T1 was from 4.9 to 9.1 out of 10. Among the 44 participants who completed incorpoRATE at both time points, the mean scores were 7.0 ± 1.0 at T1 and 7.4 ± 1.0 at T2 (t = -2.833, p = 0.007, Cohen's D = 0.43).

CONCLUSION

Among Family Medicine residents, the willingness to engage in SDM is highly variable. This suggests a lack of consensus in the mind of these residents about SDM. Although mean scores at T2 were significantly higher, we question the educational importance of this change.

PRACTICE IMPLICATIONS

incorpoRATE is a promising measure for educators. Understanding how willing a particular physician audience is to undertake SDM, and which elements require attention, could be helpful in designing more targeted curricula. Further research is needed to understand how the perceived stakes of a clinical situation influence physician willingness to engage in SDM.