Medical Decision Making Temporal characteristics of decisions in hospital encounters: A threshold for shared decision making? A qualitative study Eirik H. Ofstad a, *, Jan C. Frich b , Edvin Schei c , Richard M. Frankel d , Pa ˚l Gulbrandsen e,a a The Research Center, Akershus University Hospital, Lorenskog, Norway b Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway c Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway d Indiana University School of Medicine, VA HSR&D Center of Excellence, Roudebush VA Medical Center, Indianapolis, USA e Institute of Clinical Medicine, Campus Ahus, University of Oslo, Lorenskog, Norway 1. Introduction Patient-centered care has been promoted for decades [1–4]. One of its prime requisites is the involvement of patients in medical decisions, a principle built on an ethical imperative [5,6]. Change has come about slowly [7,8] and one of the major barriers to patient involvement in decisions is the inherent asymmetry of the patient-physician relationship [9–11]. Nowhere is this asymmetry greater than in hospitals, where patients are more seriously ill, and physicians are part of a complex, hierarchical, and technically diversified culture. Hospitals are also the cradle of basic physician training and socialization. We hypothesized that scrutiny of patient–physician encounters in hospitals could provide insight into the conditions under which physicians adopt and practice their skills in clinical reasoning and patient communication, hopefully illuminating why shared deci- sion making still has not covered much ground. Attempts to strengthen patients’ active involvement in medical decisions has been studied and promoted with two conceptually different approaches. Informed decision making (IDM) [12,13] has evolved within bioethics as an attempt to improve on informed consent. Shared decision making (SDM) [14–18], developed largely in general practice, aims to support patients in deliberation and determination around decisions entailing equipoise. With almost no exceptions, research on SDM and IDM targets single decisions related to a specified, predetermined topic [19–22], focusing on difficult decisions with two or more options, where medical evidence provides no clear guidance. However, most clinical encounters deal with several problems and produce several decisions, as illustrated by the work of Braddock et al. They defined a decision as ‘‘a verbal statement committing to a Patient Education and Counseling xxx (2014) xxx–xxx A R T I C L E I N F O Article history: Received 1 October 2013 Received in revised form 24 July 2014 Accepted 4 August 2014 Keywords: Medical decision making Hospital medicine Shared decision making Patient–physician communication Physician behavior A B S T R A C T Objective: To identify and characterize physicians’ statements that contained evidence of clinically relevant decisions in encounters with patients in different hospital settings. Methods: Qualitative analysis of 50 videotaped encounters from wards, the emergency room (ER) and outpatient clinics in a department of internal medicine at a Norwegian university hospital. Results: Clinical decisions could be grouped in a temporal order: decisions which had already been made, and were brought into the encounter by the physician (preformed decisions), decisions made in the present (here-and-now decisions), and decisions prescribing future actions given a certain course of events (conditional decisions). Preformed decisions were a hallmark in the ward and conditional decisions a main feature of ER encounters. Conclusion: Clinical decisions related to a patient–physician encounter spanned a time frame exceeding the duration of the encounter. While a distribution of decisions over time and space fosters sharing and dilution of responsibility between providers, it makes the decision making process hard to access for patients. Practice implications: In order to plan when and how to involve patients in decisions, physicians need increased awareness of when clinical decisions are made, who usually makes them, and who should make them. ß 2014 Published by Elsevier Ireland Ltd. * Corresponding author at: The Research Center, Akershus University Hospital, No-1478 Lorenskog, Norway. Tel.: +47 91 18 55 81; fax: +47 75 53 47 42. E-mail addresses: eirikofstad@gmail.com, ehof@nlsh.no (E.H. Ofstad). G Model PEC-4865; No. of Pages 7 Please cite this article in press as: Ofstad EH, et al. Temporal characteristics of decisions in hospital encounters: A ?threshold for shared decision making? A qualitative study. Patient Educ Couns (2014), http://dx.doi.org/10.1016/j.pec.2014.08.005 Contents lists available at ScienceDirect Patient Education and Counseling jo ur n al h o mep ag e: w ww .elsevier .co m /loc ate/p ated u co u http://dx.doi.org/10.1016/j.pec.2014.08.005 0738-3991/ß 2014 Published by Elsevier Ireland Ltd.