Decisional Stakes and Patient-Provider Incongruence during Shared Decision Making: A Family Medicine Resident Perspective

Context: Training in shared decision-making (SDM) typically occurs during postgraduate medical education. In their practice, residents will experience situations of patient-provider incongruence regarding next steps to care. Little is known about resident comfort in providing care when patient perspectives misalign with their own during SDM.

Objective(s): (i) Assess how Family Medicine (FM) resident perceptions of situational stakes influences their comfort providing care when faced with patient incongruence and (ii) describe what FM residents consider to be high versus low stakes situations for engaging in SDM with patients.

Study Design and Data Analysis: Sequential explanatory mixed methods. Quantitative: Descriptive statistics on a 7-item measure of willingness to engage in SDM completed by XX residents. Qualitative: Using extreme case-sampling of quantitative results, we conducted a content analysis of 16 resident interviews about what they considered to be high versus low stakes situations for SDM and how this affected their comfort when providing care in the context of patient-provider incongruence.

Integration: Quantitative and qualitative results were compared and combined.

Setting: McGill University Department of Family Medicine, Montreal.

Population: First year FM residents who attended an academic-half day session about SDM.

Intervention/Instrument: IncorpoRATE, a 7-item measure of physician willingness to engage in SDM, where items were rated from 0-10.

Outcome Measures: 1. Willingness to engage in SDM. 2. Comfort with SDM across high and low stakes situations of perceived incongruence between patient and provider.

Results: Residents were generally willing to engage in SDM (insert IncorpoRATE mean score + SD). Residents expressed higher comfort with incongruent patient choice when the stakes were perceived as low (7.59 [2.01]) versus high (4.38 [2.47]). Qualitative findings revealed variation in types of decisions residents considered to be at low and high stakes for SDM. For some decisions e.g., prostate specific antigen testing to screen for prostate cancer, we observed a lack of consensus as to whether this was high or low stakes. Factors that increased or decreased resident comfort with patient incongruence were patient health literacy, perceived consequences, involvement of proxy decision makers, administrative and legal concerns, and perceived therapeutic alliance.

Conclusions: Residents are less comfortable with incongruent patient pre