Observing decision-making in the general practice consultation: who makes which decisions?

Understanding how decisions are made in primary care consultations is essential for improving patient engagement. Prior research has shown that most decisions in clinical settings are physician-led, with limited patient involvement. However, gaps remain in identifying the full range of decision-making opportunities beyond medical treatment. No prior work had resolved how patient preferences align with objective measures of decision-making. That uncertainty drove this study to explore the types of decisions made during general practice appointments and how they are distributed between doctors and patients. This gap motivated the development of a new coding instrument to capture decision-making opportunities in consultations. Prior research has shown that patient perceptions of shared decision making may not always match objective assessments. This study aimed to clarify how often and in what ways patients are involved in decisions during consultations. The lack of standardized tools for measuring decision-making in primary care presented a challenge for prior investigations.

This study aimed to examine the types and frequency of decision-making opportunities in general practice consultations. The specific problem addressed was the lack of objective measures to assess how decisions are shared between doctors and patients. The motivation stemmed from the need to improve patient-centered care in primary care settings. Researchers sought to determine whether doctors vary in their ability to meet patient preferences for involvement in decisions. The study also aimed to compare patient self-reports with objective ratings of decision-making. By using a novel coding instrument, the researchers could better understand the full scope of decision-making in consultations. The goal was to identify areas where patient involvement could be increased. This work addresses a critical gap in understanding how decision-making is structured in primary care.

The study involved observing doctor-patient consultations in general practice settings across 12 surgeries in Oxfordshire. A total of 212 consultations were video-recorded for analysis. Patients completed questionnaires to report their perceptions of decision-making. The researchers developed a new coding instrument called the Evidence Based Patient Choice Instrument (EBPCI) to classify decision-making opportunities. The EBPCI was used to code the video recordings for types and frequency of decisions. In addition, 149 recordings were rated using the Oxbridge Rating Scale to assess consultation styles. The study focused on decisions beyond medical treatments, such as those related to lifestyle advice or care planning. The combination of patient self-reports and objective coding allowed for a comprehensive analysis of decision-making patterns.

The study found that decisions in consultations extended beyond medical treatment to include areas like lifestyle advice and care planning. Doctors typically led most decisions, with the exception of 'fitness for work' decisions. Patient self-reports showed only moderate agreement with objective ratings from the EBPCI. There was wide variation among doctors in their ability to meet patient preferences for involvement. Some doctors were significantly more successful than others at aligning with patient preferences. The EBPCI identified multiple decision-making opportunities in each consultation. Doctors with higher consultation skills were more likely to meet patient preferences for involvement. The findings suggest that patient involvement in decision-making could be increased in primary care consultations.

The authors suggest that decision-making in general practice consultations is broader than previously recognized. They propose that opportunities for patient involvement exist beyond medical treatments. The study indicates that some doctors are more successful than others at meeting patient preferences. The researchers highlight the importance of consultation skills in influencing patient perceptions of shared decision making. The findings suggest that training could improve doctors' ability to meet diverse patient preferences. The authors propose that objective measures like the EBPCI can provide a clearer picture of decision-making patterns. They suggest that increasing patient involvement in non-medical decisions could enhance patient satisfaction. The study supports the idea that patient-centered care requires more structured approaches to decision-making.