HOW DOCTORS AND PATIENTS DISCUSS ROUTINE CLINICAL DECISIONS - INFORMED DECISION-MAKING IN THE OUTPATIENT SETTING

OBJECTIVE: To characterize the informed consent process in routine, pr imary care office practice. DESIGN: Cross-sectional, descriptive evalu ation of audiotaped encounters. SETTING: Offices of primary care physi cians in Portland, Oregon. PARTICIPANTS: Internists (54%) and family p hysicians (46%), and their patients. MEASUREMENTS AND MAIN RESULTS: Au diotapes of primary care office visits from a previous study of doctor -patient communication were coded for the number and type of clinical decisions made. The discussion between doctor and patient was scored a ccording to six criteria for informed decision making: description of the nature of the decision, discussion of alternatives, discussion of risks and benefits, discussion of related uncertainties, assessment of the patient's understanding and elicitation of the patient's preferen ce. Discussions leading to decisions included fewer than two of the si x described elements of informed decision making (mean 1.23, median 1. 0), most frequent of these was description of the nature of the decisi on (83% of discussion). Discussion of risks and benefits was less freq uent (9%), and assessment of understanding was rare (2%). Discussions of management decisions were generally more substantive than discussio ns of diagnostic decisions (p = .05). CONCLUSIONS: Discussions leading to clinical decisions in these primary care settings did not fulfill the criteria considered integral to informed decision making. Physicia ns frequently described the nature of the decision, less frequently di scussed risks and benefits, and rarely assessed the patient's understa nding of the decision.