Direct-Observation Cohort Study of Shared Decision Making in a Primary Care Clinic

Background. Observational studies suggest that shared medical decision making (SMDM) is suboptimal. Our objective was to assess patient preferences, ratings, and objective measurements of decision making and their impact on patient outcomes. Methods. Hypertensive adults presenting for routine care with their primary care physician completed previsit surveys assessing SMDM preferences. Postvisit surveys assessed the degree of SMDM during the encounter, patient satisfaction, and trust. Encounters were audiotaped and transcripts were coded for type of decisions made as well as SMDM quality using OPTION-5. Adherence and blood pressure were measured at baseline and at 4 weeks. Results. Among 105 encounters, there were 7.4 decisions per visit; most were basic, such as refills and routine testing. Objective measures of decision making indicated that the degree of SMDM was lower than reported by patients or physicians, although physician ratings were more accurate. Previsit, 54% of patients expressed a desire for equally shared medical decision making, 24% preferred physician dominated decision making, and 18% preferred that they make the decisions. Postvisit, patients reported experiencing SMDM in 57% of encounters, with high concordance between desired and perceived decision making. Discordance between the patient's desired and experienced SMDM reduced trust and satisfaction. The quality of shared decisions had no impact on adherence or blood pressure at 4 weeks. Limitations. Single site, small sample. Conclusions. Decisions are common during internal medicine primary care visits, and most are basic. Most patients preferred SMDM, and their perceptions of the visit decision-making style were concordant with their preferences although higher than objective measures suggested. Physician ratings of the quality of SMDM were more accurate than patient ratings. Discordance between patients' expected and experienced SMDM lowered satisfaction and trust.