Context Many clinicians have called for an increased emphasis on the patient's
role in clinical decision making. However, little is known about the extent
to which physicians foster patient involvement in decision making, particularly
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 surgeons.
Design Cross-sectional descriptive evaluation of audiotaped office visits during
Setting and Participants A total of 1057 encounters among 59 primary care physicians (general
internists and family practitioners) and 65 general and orthopedic surgeons;
2 to 12 patients were recruited from each physician's community-based private
Main Outcome Measures Analysis of audiotaped patient-physician discussions for elements of
informed decision making, using criteria that varied with the level of decision
complexity: basic (eg, laboratory test), intermediate (eg, new medication),
or complex (eg, procedure). Criteria for basic decisions included discussion
of the nature of the decision and asking the patient to voice a preference;
other categories had criteria that were progressively more stringent.
Results The 1057 audiotaped encounters contained 3552 clinical decisions. Overall,
9.0% of decisions met our definition of completeness for informed decision
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 most frequently
(71%) and assessment of patient understanding least frequently (1.5%).
Conclusions Informed decision making among this group of primary care physicians
and surgeons was often incomplete. This deficit was present even when criteria
for informed decision making were tailored to expect less extensive discussion
for decisions of lower complexity. These findings signal the need for efforts
to encourage informed decision making in clinical practice.