Shared decision making and the concept of equipoise: the competences of involving patients in healthcare choices.

TLDR

Patient involvement in healthcare decisions can significantly improve outcomes, yet its definition remains vague, often conflated with broad patient‑centredness that is hard to measure, and the necessary interpersonal skills and information demands pose major challenges that warrant higher priority in policy, education, and professional development. The study aims to assess GPs’ attitudes toward patient involvement, identify contextual factors, competences, and stages needed for shared decision making, and propose a skill set and procedural steps for generalists. The authors propose an eight‑step skill sequence: initiating patient involvement, exploring ideas and expectations, presenting equipoise and options, tailoring information, confirming understanding, clarifying decision‑making role preferences, making or deferring decisions, and arranging follow‑up. GPs view cooperative decision making as suitable for certain problems, see professional equipoise among legitimate options as facilitative, and hold positive attitudes toward patient involvement when the process aligns with patients’ preferred roles.

Abstract

Involving patients in healthcare decisions makes a potentially significant and enduring difference to healthcare outcomes. One difficulty (among many) is that the 'involvement' of patients in decisions has been left undefined. It is usually conceptualised as 'patient centredness', which is a broad and variably interpreted concept that is difficult to assess using current tools. This paper attempts to gauge general practitioners' (GPs') attitudes to patient involvement in decision making and their views about the contextual factors, competences, and stages required to achieve shared decisions within consultations.To explore and understand what constitutes the appropriate involvement of patients in decision making within consultations, to consider previous theory in this field, and to propose a set of competences (skills) and steps that would enable clinical practitioners (generalists) to undertake 'shared decision making' in their clinical environment.Qualitative study using focus group interviews of key informants.Experienced GPs with educational roles have positive attitudes to the involvement of patients in decisions, provided the process matches the role individuals wish to play. They perceive some clinical problems as being more suited to a cooperative approach to decision making and conceptualised the existence of professional equipoise towards the existence of legitimate treatment options as an important facilitative factor. A sequence of skills was proposed as follows: 1) implicit or explicit involvement of patients in the decision-making process; 2) explore ideas, fears, and expectations of the problem and possible treatments; 3) portrayal of equipoise and options; 4) identify preferred data format and provide tailor-made information; 5) checking process: understanding of information and reactions (e.g. ideas, fears, and expectations of possible options); 6) acceptance of process and decision making role preference; 7) make, discuss or defer decisions; 8) arrange follow-up.These clinicians viewed involvement as an implicit ethos that should permeate medical practice, provided that clinicians respect and remain alert to patients' individual preferred roles in decision making. The interpersonal skills and the information requirements needed to successfully share decisions are major challenges to the clinical consultation process in medical practice. The benefits of patient involvement and the skills required to achieve this approach need to be given much higher priority at all levels: at policy, education, and within further professional development strategies.