Informed decision making in outpatient practice - Time to get back to basics

Context Many clinicians have called for an increased emphasis on the patien t's role in clinical decision making. However, little is known about the ex tent to which physicians foster patient involvement in decision making, par ticularly in routine office practice. Objective To characterize the nature and completeness of informed decision making in routine office visits of both primary care physicians and surgeon s. Design Cross-sectional descriptive evaluation of audiotaped office visits d uring 1993, Setting and Participants A total of 1057 encounters among 59 primary care p hysicians (general internists and family practitioners) and 65 general and orthopedic surgeons; 2 to 12 patients were recruited from each physician's community-based private office. Main Outcome Measures Analysis of audiotaped patient-physician discussions for elements of informed decision making, using criteria that varied with t he level of decision complexity: basic (eg, laboratory test), intermediate (eg, new medication), or complex (eg, procedure), Criteria for basic decisi ons included discussion of the nature of the decision and asking the patien t to voice a preference; other categories had criteria that were progressiv ely more stringent, Results The 1057 audiotaped encounters contained 3552 clinical decisions. O verall, 9.0% of decisions met our definition of completeness for informed d ecision making, Basic decisions were most often completely informed (17.2%) , while no intermediate decisions were completely informed, and only 1 (0.5 %) complex decision was completely informed. Among the elements of informed decision making, discussion of the nature of the intervention occurred mos t frequently (71%) and assessment of patient understanding least frequently (1.5%). Conclusions Informed decision making among this group of primary care physi cians and surgeons was often incomplete. This deficit was present even when criteria for informed decision making were tailored to expect less extensi ve discussion for decisions of lower complexity. These findings signal the need for efforts to encourage informed decision making in clinical practice .