Physician Communication: Barriers to Achieving Shared Understanding and Shared Decision Making with Patients
Summary: Patient involvement in their health care is likely to reduce errors, adverse events, and nonadherence to treatment. Emphasis is being increasingly placed on developing partnerships between patients, physicians, and other health professionals. This may also reduce the economic burden of chronic disease and enhance healing and illness management. Our study investigates the specific barriers between physicians and patients that inhibit shared understanding and shared decision making.
Survey data were collected during the fall of 2006 from 278 physicians in the province of Manitoba, Canada. Family medicine was the largest specialty at 40% followed by internal medicine. The respondents had a mean of 16.49 years of practice and 60% were male. Participants were asked to indicate problems they had communicating with patients. A principal components factor analysis was used to cluster these items into shared understanding and shared decision making.
Factor 1 (shared understanding) was comprised of five items with the patient presenting with too many problems as the greatest barrier. Factor 2 (shared decision making) was comprised of nine items with the patient does not appear to trust the physician as the greatest barrier.
Our findings indicate that a systems approach is needed to empower and involve patients in their health care decisions, with the building of social capital to increase the adoption of healthy behavioral norms.
Keywords: Shared decision making, chronic illness management, patient safety, health promotion, shared understanding, patient advocacy.
Citation: Lovell BL, Lee RT, Brotheridge CM. Physician communication: barriers to achieving shared understanding and shared decision making with patients. J Participat Med. 2010 Oct 13; 2:e12.
Published: October 13, 2010.
Competing Interests: The authors have declared that no competing interests exist.
Patient involvement in their health care is likely to reduce errors, adverse events, and nonadherence to treatment. Emphasis is being increasingly placed on developing partnerships between patients, physicians, and other health professionals. This may also reduce the economic burden of chronic disease and enhance healing and illness management. This taxonomy of behaviors has been labeled shared decision making (SDM), which prior studies have examined using qualitative and quantitative methods. SDM is appropriate in any situation where there is more than one reasonable course of action and where a single option is not readily apparent. McNutt contends that patients must decide on their own course of treatment once they understand all of the pertinent information. The physician often provides initial information about available options, ensuring that patients understand the ramifications of their choices. But, before provider and patient can engage in SDM, there must be a shared understanding of each other’s frame of reference.
Qualitative studies conducted in the 1990s by researchers in Great Britain and Sweden investigated shortcomings in the physician-patient relationship that inhibit shared understanding. Patients emphasized that, to achieve understanding, they must communicate with providers at the same or a similar level. However, the level of health literacy, absence of patients’ feeling of empowerment, insufficient access to information, beliefs about illness, and relationship styles have all been shown to inhibit understanding. Successful consultation depends on developing a reciprocal understanding, and is crucial for patients with chronic illnesses such as obstructive pulmonary disease. Patients believe that emotional safety helps to empower them to engage in SDM. For example, positive expression of emotions by physicians toward patients has been shown to be strongly associated with shared understanding. Patients assert that the most important factor in fostering SDM is a physician who demonstrates good interpersonal skill. On the other hand, physicians consider the ability of the patient to provide complete and accurate information as the most important factor. A trusting relationship may be the most fundamental determinant of patients’ willingness to engage in SDM. Trusting relationships are more likely to succeed when developed over time and when they are in the context of a continuous relationship with the provider. For example, patients may conceal use of complementary and alternative treatment approaches to avert disapproval from their health care provider.
Taking sufficient time to discuss the ramifications of the treatment plan in a nonjudgmental way may help to minimize potential risks and facilitate optimum patient wellbeing. Physicians who spend more time with patients tend to have communication styles that result in a greater degree of SDM. In contrast, physicians having higher volumes of patients who spend less time with them tended to be less participatory. Both patients and physicians agree that time pressure is a significant barrier to shared decision making.
The authors undertook to measure specific barriers that were reported by physicians as inhibiting shared understanding and shared decision making with patients.
Survey data were collected during the fall of 2006 in the province of Manitoba, Canada. A self-report questionnaire was distributed through the provincial medical association’s bimonthly newsletter to its members and by a direct mailing from the researchers to the work addresses of the physicians obtained from the public access website of the College of Physicians and Surgeons of Manitoba. Completed questionnaires were returned to the first author. We received 278 responses, 53% from the provincial medical association, and 47% from the College. The respondents’ mean years of practice was 16.49 (SD = 11.05), 60% were male, and 84% were white. The mean percentage of time spent in patient care was 68% (SD = 24%); the mean number of minutes spent per patient was 19.04 (SD = 14.76). On average, the respondents reported that 58% of their patients were female (SD = 14.62), 42% were male (SD = 11.82); 63% of patients were white (SD = 23.83), 24% were Aboriginal (SD = 21.35), and 13% were from other ethnic groups (SD = 9.16). The various specialties were classified into the following groups: family medicine (n = 110), internal medicine (n = 60), pediatric disciplines (n = 30), surgical disciplines (n = 29), residents (n = 20), psychiatry (n = 19), other (n =10).
Part C of the Doctor-Patient Communication Needs Assessment scale (18 items) asked the participants about specific difficulties they have in communicating with patients from different cultural and socio-economic backgrounds. The participants’ responses were rated on a scale of 1 to 5 with 1 being “none” and 5 “extremely serious.” A principal components analysis (PCA) with varimax rotation of the 18 communication items was performed to determine whether the correlations among the items supported the factors of shared understanding and shared decision making. PCA is a form of factor analysis that is used to detect the underlying relationships among items. Linear combinations that maximize the amount of explained variance among the items are grouped together as distinct factors. As an iterative approach, the amount of variance explained by the first factor is first extracted. Then the amount of the remaining variance explained by the second factor is extracted. The number of extractions is based on the criterion of factors having eigenvalues of 1.0 or greater. To facilitate interpretation, only items that loaded 0.50 or higher on either factor with no cross-loading were retained.
Table 1 shows the 18 items rank-ordered by their means. Of these items, patients not following through with treatment plans (mean = 3.29), insufficient time (mean = 3.28), difficulties getting patients to understand diagnosis (mean = 3.07), and getting patients to understand the implications of their diagnosis (mean = 3.06), were the furthest above the scale midpoint and the most serious communication barriers from the physicians’ perspective. Patients using culturally based alternative therapies that the physician is unfamiliar or disagrees with (mean = 2.45), and patient does not appear to trust the physician (mean = 2.53), were the furthest below the scale midpoint and the least serious communication barriers.
Table 1. Means of the 18 Communication Barriers
Response scale for each item: “Extent of problem when communicating with patients of different cultural and/or socioeconomic backgrounds”: 1 = None; 2 = Slight; 3 = Moderate; 4 = Fairly serious; 5 = Extremely serious.
Table 2 shows that the factors of shared understanding and shared decision making had eigenvalues of 5.48 and 2.93, respectively, and the percentages of variance extracted were 30.31 and 16.26, respectively. Factor 1 was comprised of five items related to shared understanding grouped into the following subcategories: patient management, presentation of symptoms, and explanation and planning. Factor 2 was comprised of nine items related to shared decision making grouped into the following subcategories: explanation and planning, cultural beliefs and practices, health maintenance behaviors, and partnership-building behaviors. The other four items (numbers 5, 11, 14, and 16 in Table 1) did not load significantly on either factor and were not included in our analysis. The greatest individual barrier to shared understanding was the “patient presenting with too many problems” (.70). The greatest individual barrier to shared decision making was “patient does not appear to trust the physician” (.84). Overall, the patients’ health maintenance and partnership-building behaviors were the greatest barriers to shared decision making (Factor 2) and higher than all of the barriers to shared understanding with the exception of one (Factor 1).
Although the concept of shared understanding is an integral part of the decision-making process, there is little research that addresses this area. If patients did not feel that they have been adequately informed or the physician did not feel that the patient’s recall of symptoms and problems could be understood, then neither participant is likely to be motivated to participate in SDM. This may explain why “patient’s history is rambling and disorganized” (.67), “patient presents too many problems” (.70), and as a follow-up, “patient does not want to participate in a partnership with physician” (.77) were highly correlated with lack of shared understanding.
Successful SDM requires that patients be able to follow through with the treatment plan once it has been established. The provider should ensure that the patient’s context and life circumstances have been taken into account and that the appropriate support mechanisms are available. Our findings revealed that patients often have difficulties following through with treatment and engaging in self-care practices. This may indicate that motivation, education, and social and community support may often be inadequate. Physicians who coordinate care effectively and have continuous relationships with patients are more likely to observe chronically ill patients who follow through with their treatment, rate their care as excellent, and have greater success in managing their illness. Electronic health records and high-quality after-hours care are important factors that support patients with chronic illnesses. However, less than 50% of Canadian doctors use electronic records or coordinate care after hours.
Our findings also indicated that the greatest and most significant barrier to SDM was lack of trust in physicians. Patients will not feel comfortable speaking up and asking questions where there is mistrust. Interpersonal skills and relationship building were considered to be the most powerful facilitator for SDM, especially among ethnic minorities. A study of patients from a family practice clinic indicated that physician behaviors most strongly correlated with trust were a comforting and caring approach, a provider who demonstrates a high level of competency, and a provider who has expressive communication. Our physicians indicated that insufficient time was a barrier to shared understanding, which may lead to patients feeling that they have not been adequately informed. Patients in another study indicated that they may have themselves contributed to a shorter visit because they felt guilty for taking up too much of the doctor’s time. Patients who leave the consultation with unanswered questions and inadequate information are less inclined to participate in shared decision making.
Future studies should address the limitations of our study. In particular, since self-report bias may have occurred with our participants, it is important to also obtain the perspective of the patient. Although the structure of this study was appropriate given the research question asked, future studies utilizing patient responses could provide more insight into some of the barriers that the physicians have reported, as well as identifying others that haven’t been identified here.
In summary, our study has shed light on the barriers to shared understanding and decision making at both micro and macro levels from the physicians’ perspective, and has implications for efforts to improve patient participation. Our findings further suggest that a systems approach is needed to empower and involve patients in their health care decisions.
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Copyright: © 2010 Brenda L. Lovell, Raymond T. Lee, and Celeste M. Brotheridge. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author(s), with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.
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