Challenges in family practice related to informed and shared decision-making: a survey of preceptors of medical students.

© 2001 Canadian Medical Association or its licensors Although the informed involvement of patients in shared decision-making is commonly acknowledged to be an ideal situation, this is rarely achieved, leading to important adverse consequences. It can be a communication challenge for clinicians to involve patients in informed and shared decision-making (ISDM). We defined the “competencies” needed for ISDM in order to address this problem systematically through medical education. These competencies are communication skills related to building of partnerships; eliciting of preferences for receiving information and playing a role in decision-making; exploring of ideas, concerns and expectations; presenting of choices and evidence; reaching a decision and resolving conflict; and agreeing on an action plan and follow-up. In this study, we asked, What are the most frequent and challenging situations that require ISDM skills experienced by family practice preceptors of medical students? The information could be used to refine training in communication skills, because students and preceptors are likely to be motivated to learn approaches to difficult and common problems. It has been reported that the “difficult patient” occurs in 10%–20% of primary care encounters, but the terms used in the substantial “difficult patient” literature do not seem to be congruent with the “difficulties” that physicians may have in engaging patients in ISDM. Some examples that do seem relevant have been suggested by Platt and Gordon: “nonadherence,” “the list maker,” “the patient’s companion,” “the patient bearing literature” and, in a survey of general practitioners’ frequent problems, “patient’s noncompliance with treatment and follow-up,” “sharing understanding of the problem with the patient” and “differences in expectations between physician and patient.” We wrote survey questions to portray generic situations in physician–patient encounters that pose a challenge to ISDM. The scenarios were developed and refined by stepwise and iterative consultation with physicians who had wide experience in teaching and examining communication skills and had helped to define the competencies for ISDM. The survey form was constructed with the attention to deChallenges in family practice related to informed and shared decision-making: a survey of preceptors of medical students