Abstract
PURPOSE Communication has been researched either as a set of behaviors or as a facet of the patient-physician relationship, often leading to conflicting results. To determine the relationship between these perspectives, we examined shared decision making (SDM) and the subjective experience of partnership for patients and physicians in primary care.
METHODS From a convenience sample of experienced primary care physicians in 3 clinics, we recruited a stratified sample of 18 English- or Spanish-speaking patients. Direct observation of visits was followed by videotape-triggered stimulated recall sessions with patients and physicians. We coded decision moments for objective evidence of SDM, using a structured instrument. We classified patients’ and physicians’ subjective experience of partnership as positive or negative by a consensus analysis of stimulated recall sessions. We combined results from these 2 analyses to generate 4 archetypes of engagements and used grounded theory to identify themes associated with each archetype.
RESULTS The 18 visits yielded 125 decisions, 62 (50%) of which demonstrated SDM. Eighty-two decisions were discussed in stimulated recall and available for combined analysis, resulting in 4 archetypes of engagement in decision making: full engagement (SDM present, subjective experience positive)—22%; simulated engagement (SDM present, subjective experience negative)—38%; assumed engagement (SDM absent, subjective experience positive)—21%; and nonengagement (SDM absent, subjective experience negative)—19%. Thematic analysis revealed that both relationship factors (eg, trust, power) and communication behavior influenced subjective experience of partnership.
CONCLUSIONS Combining direct observation and assessment of the subjective experience of partnership suggests that communication behavior does not ensure an experience of collaboration, and a positive subjective experience of partnership does not reflect full communication. Attempts to enhance patient-physician partnership must attend to both effective communication style and affective relationship dynamics.
Footnotes
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Conflicts of interest: none reported
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Funding support: The work for this article was funded primarily by grant 5P01 HS10856 from the Agency for Healthcare Research and Quality for an Excellence Center to Eliminate Ethnic/Racial Disparities (EXCEED) to the University of California, San Francisco, Medical Effectiveness Research Center for Diverse Populations (MERC). Dr Schillinger was supported by grant K23 RR16539. Dr Fernandez was supported by grant K23 RR1018324.
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Disclaimer: The sponsors had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript.
This work was presented in part at the American Public Health Association Annual Meeting, November 2003, San Francisco, Calif; the Society for General Internal Medicine Annual Meeting, May 2004, Chicago, Ill; the International Conference on Communication and Healthcare, September 2004, Bruges, Belgium; and the Society of Teachers of Family Medicine Annual Spring Conference, Distinguished Research Presentation, May 2005, New Orleans, La.
- Received for publication February 28, 2005.
- Revision received May 23, 2005.
- Accepted for publication June 6, 2005.
- © 2006 Annals of Family Medicine, Inc.