Patient–doctor decision-making about treatment within the consultation—A critical analysis of models
Introduction
In this paper we want to explore some of the limitations of models of patient involvement in treatment decision-making. Specifically, we will consider the models of interpretative decision-making, shared decision-making and informed decision-making. To some extent these limitations are simply limitations of models (i.e. models are inherently and necessarily limited—that is, so-to-speak, how they work), and we will begin by acknowledging this fact. But we also want to highlight two aspects of the process of decision-making, which, we would argue, are crucial to an understanding of doctor–patient decision-making and yet are substantially neglected by the models. These two aspects relate to the questions ‘which decisions should patients be involved in?’ and ‘how should patients be involved in decision-making?’ More specifically they concern (1) the framing problem—the construction of the option-set which both frames decision-making and is, in part, a product of decision-making; (2) the nature of reasoning problem—the nature of the reasoning–communication represented in any process of joint decision-making. Lying behind these limitations, we want to suggest, is a more fundamental problem. We would argue that whilst these models represent some very important aspirations, they pay insufficient attention to, and are insufficiently explicit about, the dilemmas of professional ethics which are played out in professional–patient relationships. This, it seems to us, is where their real limitation lies.
In the main body of the paper we will not spend much time interrogating the nature and variety of models. We will proceed as if the models discussed have relatively clear-cut and broadly similar purposes. However, it is essential to signal at the outset that the role and value of these kinds of model are both contested and varied. However, one thing that might be said by way of generalisation is that it is in the nature of models to ‘abstract from’ and simplify the multi-dimensional realities that they represent. (As is often said a ‘map’ which contained all the information found in the reality it depicted would be valueless as a map.) It is, therefore, not a credible criticism of models to point out that they do not include all the things that they might include. Nor can we expect there to be any straightforward ‘match’ between models and the world of practice. There is inevitably an ‘interpretative space’ between the models and practice. Thus, it is not simply that there may sometimes be a kind of mismatch between a model and practice, it is also that we are often unsure what would count as an application of a specific model in real-world circumstances.
Having acknowledged some of these complexities we will take it that models of patient involvement are designed to describe and/or prescribe some conception of ‘good practice’, i.e. patient involvement is being made salient through the models because of its instrumental or intrinsic value. Instrumental (or practical) value refers to such things as patient involvement leading to patients who “make wiser decisions, come to a common understanding with their physicians, and adhere more fully to treatment” (Epstein, Alper, & Quill, 2004); hopefully this leads to a happier, healthier patient. Intrinsic value refers to philosophical or ethical ideals, such as ‘respect for persons’, which underlie or inform patient involvement policies; ideals that can be seen as crucially important in themselves, irrespective of the practical effects of involvement. Given that this account describes the basic thrust underpinning models such as the ones considered here, there are three broad sets of evaluative issues that arise about the ‘space’ between models and practice. We could, for example, ask (1) Is there a rough fit between (any of) these models and some real world practices? (2) What are the factors that might enable or constrain the possible realisation and enactment of the model in practice? (3) Do (or would) enactments of the models serve the instrumental or intrinsic ends that their advocates would wish? The remarks we make in the review of the models that make up the main body of the paper will touch upon all of these questions, but these questions do not form the central thread of our account. Rather, as we have already indicated, we will concentrate on exploring what we see as some of the limitations of the models—limitations which, we would argue, make it difficult to answer any of these questions satisfactorily. These models of doctor–patient decision-making, we are suggesting, are not sufficiently well-defined to answer these crucial evaluative questions. It seems to us that before they can be subjected to these kinds of evaluations the underlying assumptions that these models make about the relative roles of professionals and patients need to be questioned and further elaborated.
Section snippets
Describing the decision-making models
Currently, there are four frequently discussed models of patient–doctor decision-making about treatment: Paternalistic decision-making, interpretative decision-making, shared decision-making and informed decision-making (Emanuel & Emanuel, 1992; Laine & Davidoff, 1996; Charles, Gafni, & Whelan (1997), Charles, Gafni, & Whelan (1999a), Charles, Gafni, & Whelan (1999b)). There is no universally agreed definition of these models and what they include. On the contrary, there is much confusion and
Limitations of the decision-making models
What are the relationships between these models and clinical realities? As we have noted earlier it does not make sense to look for complete or tidy matches between the two. However, in analysing the decision-making models we found two substantial limitations which, we suggest, means that the use of these models for understanding doctor–patient decision-making within the consultation needs to be questioned and re-evaluated. These limitations also shed light on the reasons why models such as
Concluding discussion
These models, we have argued, fall short because they give insufficient attention both to which decisions are in the lens (the framing problem) and to the question of how decisions should be made (the nature of reasoning problem). Because these are two such fundamental considerations it seems to us that any useful model will have to address them more directly. However we would also want to argue that the task of addressing these questions entails facing up to fundamental dilemmas about the
Acknowledgement
The authors want to thank the School of Pharmacy, University of London for funding the research presented in this paper. We are very grateful to all three anonymous reviewers for their very thorough and helpful readings of our paper and their suggestions for strengthening it.
References (28)
- et al.
Shared decision-making in the medical encounter: What does it mean? (Or it takes at least two to tango)
Social Science & Medicine
(1997) - et al.
Decision-making in the physician-patient encounter: Revisiting the shared treatment decision-making model
Social Science & Medicine
(1999) - et al.
Measuring the involvement of patients in shared decision-making: A systematic review of instruments
Patient Education & Counseling
(2001) - et al.
What are the ingredients for a successful evidence-based patient choice consultation? A qualitative study
Social Science & Medicine
(2003) - et al.
Shared treatment decision making in a collectively funded health care system: Possible conflicts and some potential solutions
Social Science & Medicine
(2002) - et al.
Integrated decision making: Definitions for a new discipline
Patient Education and Counseling
(2003) Evidence and risk: The sociology of health care grappling with knowledge and uncertainty
- et al.
Competence in mental health care: A hermeneutic perspective
Health Care Analysis
(2004) - et al.
Informed decision making in outpatient practice, time to get back to basics
Journal of the American Medical Association
(1999) - et al.
Misunderstandings in prescribing decisions in general practice: Qualitative study
British Medical Journal
(2000)
Shared decision-making in question
Psycho-oncology
What do we mean by partnership in making decisions about treatment?
British Medical Journal
Paternalism or partnership?
British Medical Journal
Health and the good society
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