Understanding Agency in Shared Decision Making: A Qualitative Analysis of Clinical Encounters and Patient-Physician Interviews.

Abstract

Purpose: Shared decision making is highly encouraged in patient-centered care but can be difficult to implement in practice. Although lack of training has been implicated as an obstacle to successful shared decision making, consensus has not been reached about the most effective educational interventions. 1–3 We propose that the coconstruction of clinical decisions is a complex activity, requiring patient and relational agency, and cultural historical activity theory (CHAT) can be used as a framework to help health professions researchers and educators understand and teach shared decision making. 4 The objective of this qualitative study was to use CHAT to explore, through analysis of clinical encounters and focused interviews, both patient and provider perspectives of the contraceptive decision-making process. A better understanding of shared decision making can inform more effective educational interventions for our learners and potentially improve patient outcomes. Approach/Methods : We recruited female patients between the ages of 17 and 45 who used a contraceptive decision aid mobile application (app) before a visit to a walk-in contraceptive clinic. Physicians providing care to these women in the clinic were also recruited. We audio-recorded the clinical encounter and, following the encounter, we conducted semistructured interviews with each patient and physician separately. We used template analysis to analyze the 63 transcripts (interviews and clinical recordings). For each patient, we considered the collection of their interview, the provider’s interview, and the clinical recording as a single case. Analysis was conducted within and across cases. The initial template was created to guide the identification of elements of CHAT, tensions within and between accounts of the patients, physicians and the clinical encounter, and evidence of patient and relational agency. The template was modified iteratively and new themes were defined and codes added into the template. Results/Outcomes: Twenty-one patients and 8 providers participated, creating 21 cases. Evidence of each CHAT element, including subject, object, tool, community, rules, and division of labor, were identified in at least 1 of the 3 transcripts for each patient–physician dyad. For example, “tools” that were used by patients to achieve the object of obtaining a contraceptive method included their knowledge, previous experience, and the app. We also observed the influence of a patient’s partner or occupation on decision making, which was represented by “community.” By comparing the findings of each element between different cases and by examining occurrences of codes across the transcripts, we identified recurring themes, such as how the app is used as a “tool” in facilitating agency or the impact of both the patient’s and the physician’s “community” on shared decision making. Discussion: By analyzing clinical encounters with CHAT, we identified factors and tensions influencing behavior of individual patients and physicians when engaged in a clinical encounter about contraception. Analysis of interactions of the patient and physician activity systems revealed tensions that were resolved over the course of the encounters and allowed for an exploration of the impact of agency in the process. For example, in several cases, it was the role of “tools” and the physician’s awareness of factors such as their own and the patient’s “communities” that promoted successful shared decision making. Educational interventions that address the complexity of co-constructing decisions may result in more effective shared decision making. Significance: By using CHAT to study shared decision making, we can identify important characteristics of educational interventions for health professionals that may lead to enhanced patient agency and successful shared decision making.