Experienced barriers in shared decision‐making behaviour of orthopaedic surgery residents compared with orthopaedic surgeons

Background Although shared decision making is championed as the preferred model for patient care by patient organizations, researchers and medical professionals, its application in daily practice remains limited. We previously showed that residents more often prefer paternalistic decision making than their supervisors. Because both the views of residents on the decision-making process in medical consultations and the reasons for their ‘paternalism preference’ are unknown, this study explored residents’ views on the decision-making process in medical encounters and the factors affecting it. Methods We interviewed 12 residents from various specialties at a large Dutch teaching hospital in 2019–2020, exploring how they involved patients in decisions. All participating residents provided written informed consent. Data analysis occurred concurrently with data collection in an iterative process informing adaptations to the interview topic guide when deemed necessary. Constant comparative analysis was used to develop themes. We ceased data collection when information sufficiency was achieved. Results Participants described how active engagement of patients in discussing options and decision making was influenced by contextual factors (patient characteristics, logistical factors such as available time, and supervisors’ recommendations) and by limitations in their medical and shared decision-making knowledge. The residents’ decision-making behavior appeared strongly affected by their conviction that they are responsible for arriving at the correct diagnosis and providing the best evidence-based treatment. They described shared decision making as the process of patients consenting with physician-recommended treatment or patients choosing their preferred option when no best evidence-based option was available. Conclusions Residents’ decision making appears to be affected by contextual factors, their medical knowledge, their knowledge about SDM, and by their beliefs and convictions about their professional responsibilities as a doctor, ensuring that patients receive the best possible evidence-based treatment. They confuse SDM with acquiring informed consent with the physician’s treatment recommendations and with letting patients decide which treatment they prefer in case no evidence based guideline recommendation is available. Teaching SDM to residents should not only include skills training, but also target residents’ perceptions and convictions regarding their role in the decision-making process in consultations.

Objective To investigate the treatment decision-making process after an anterior cruciate ligament (ACL) injury from patients’, orthopaedic surgeons’ and physiotherapists’ perspectives. Methods The study is a part of the NACOX study, which is designed to describe the natural corollaries after ACL injury. For the present study, a subgroup 101 patients were included. Patients, their orthopaedic surgeons and their physiotherapists, answered a Shared Decision-Making Process (SDMP) questionnaire, when treatment decision for ACL reconstruction surgery (ACLR) or non-reconstruction (non-ACLR) was taken. The SDMP questionnaire covers four topics: “ informed patient”, “ to be heard”, “ involvement” and “ agreement”. Results Most (75–98%) patients considered their needs met in terms of being heard and agreement with the treatment decision. However, fewer in the non-ACLR group compared to the ACLR group reported satisfaction with information from the orthopaedic surgeon (67% and 79%), or for their own involvement in the treatment decision process (67% and 97%). Conclusion and practice implications Most patients and caregivers considered that patients’ needs to be informed, heard and involved, and to agree with the decision about the treatment process, were fulfilled to a high extent. However, patients where a non-ACLR decision was taken experienced being involved in the treatment decision to a lower extent. This implies that the non-ACLR treatment decision process needs further clarification, especially from the patient involvement perspective.

Background In orthopedics, the use of patient decision aids (ptDAs) is limited. With a mixed-method process evaluation, we investigated patient factors associated with accepting versus declining the use of the ptDA, patients’ reasons for declining the ptDA, and clinicians’ perceived barriers and facilitators for its use. Methods Patients with an indication for joint replacement surgery ( N = 153) completed questionnaires measuring demographics, physical functioning, quality of life (EQ-5D-3L), and a visual analog scale (VAS) pain score at 1 time point. Subsequently, their clinician offered them the relevant ptDA. Using a retrospective design, we compared patients who used the ptDA (59%) with patients who declined (41%) on all these measures as well as the chosen treatment. If the use of the ptDA was declined, patients’ reasons were recorded by their clinician and analysed ( n = 46). To evaluate the experiences of clinicians ( n = 5), semistructured interviews were conducted and thematically analyzed. Clinicians who did not use the ptDA substantially (<10 times) were also interviewed ( n = 3). Results Compared with patients who used the ptDA, patients who declined use had higher VAS pain scores (7.2 v. 6.2, P < .001), reported significantly worse quality of life (on 4 of 6 EQ-5D-3L subscales), and were less likely to receive nonsurgical treatment (4% v. 28%, P < .001). Of the patients who declined to use the ptDA, 46% said they had enough information and felt ready to make a decision without the ptDA. The interviews revealed that clinicians considered the ptDAs most useful for newly diagnosed patients who had not received previous treatment. Conclusion These results suggest that the uptake of a ptDA may be improved if it is introduced in the early disease stages of hip and knee osteoarthritis. Highlights Patients who declined the use of a patient decision aid (ptDA) for hip and knee osteoarthritis reported more pain and worse quality of life. Most patients who declined to use a ptDA felt sufficiently well informed to make a treatment decision. Patients who declined the ptDA were more likely to have received prior treatment in primary care. Clinicians found the ptDA to be a helpful addition to the consultation, particularly for newly diagnosed patients.