Decision-making style appears to reflect primarily personal factors as well as select health, social, and economic factors; however, these explanatory variables were not equally predictive of all types. Four of five factors of personality were helpful for explaining differences between the most and least active types. Only two variables, gender and rural or farm origins, distinguished the “mixed” types, those who want either deliberation or selection of treatment choice but not both, from the Nondeliberative Delegators, who want neither.
We found lower levels of two personality traits, agreeableness and neuroticism, among those individuals who prefer to make important medical decisions and participate in deliberation. Agreeableness is characterized by cooperativeness and tolerance (McCrae & Costa, 2003
); thus, agreeable individuals may be less confrontational with doctors when it comes to decision making and may not be bothered when doctors assume the traditional paternalistic role.
As hypothesized, higher neuroticism was associated with preferences for less participation. Neuroticism is characterized by anxiety and self-consciousness (McCrae & Costa, 2003
), and individuals prone to such negative affect might find discussion about treatment options and assuming personal responsibility for making important health decisions to be anxiety provoking or otherwise distressing. Maximizing decisional conflict by giving decisional control to patients has been touted as difficult but ultimately beneficial for all patients (McNutt, 2004
). Nevertheless, especially in the case of older adults for whom anxiety may impair how well they are able to devote complete attention to cognitive tasks (Hogan, 2003
), it seems important to respect the preferences of patients who prefer not to participate in health care decision making. Exploratory research on risk taking in decision making has suggested that neurotic individuals prefer less risk in decisions to achieve a gain while also preferring more risk in decisions to avoid a loss (Lauriola & Levin, 2001
). This may have additional consequences for neurotic patients, depending on the type of health decision being made, and should be explored in future work.
Two other personality traits, conscientiousness and openness to experience, were more likely to be found among those who prefer to make important medical decisions and participate in deliberation. Conscientiousness is characterized by self-discipline and ambition (McCrae & Costa, 2003
), and conscientious individuals are known to take an active role in avoiding risky health behaviors and participating in beneficial ones. It is not surprising, then, as we hypothesized, that they also prefer to take an active role in health care decision making.
Lastly, as the model of the doctor–patient relationship has changed over the lifetime of this cohort of older adults, it is likely that doctors allowed these individuals to participate in decision making only relatively recently. It is unsurprising, therefore, that those individuals who are more open have preferences for more active involvement in health care decision making, given that openness to experience is characterized by creativity and a preference for novelty.
Both gender and rural or farm origin were linked to decision-making style. Previous research has already shown that women prefer more active involvement in health care decision making (Arora & McHorney, 2000
). Although we know of no literature specifically linking rural or farm origins to health care preferences, farm origins are associated with lower socioeconomic attainment and could plausibly be associated with subcultural differences net of other sociodemographic measures, such as a preference for the more traditional doctor–patient relationship. As a colleague from a rural Iowan sheep farm explained, “Farm people, we’re different” (Jeremy Freese, personal communication, March 2, 2007).
As in previous studies, higher education was associated with preferences for more active participation in decision making. We also found that individuals with higher cognitive ability, whether measured in high school or in older age, were more likely to have the most participatory decision-making style. Individuals who have more education or are more intelligent may feel at greater ease in discussions with health care providers and have increased confidence in personal ability to make important medical decisions. Previous studies have linked less serious illness with preferences for more active participation in decisions, and although we found no relationship between SF-12 physical or mental health summary scores or the number of conditions a respondent reported, we did see a relationship between taking fewer prescription medications and wanting to be involved.
Our study has several limitations. First, it is important to note that these data are not a random sample of the country, which limits the generalizability of our results. Second, there is a lack of variation in respondent age, as over 98% of WLS respondents were born between 1938 and 1940. Nevertheless, although our findings should be validated in more diverse populations, by examining the role of personality within the WLS graduate sample, we were able to essentially control for period and cohort effects to focus on the factors within individuals that influence preferences (Giele & Elder, 1998
). Third, thus far the WLS has only obtained decision-making preferences at one point in time, so we can offer no causal inferences about personality and decision-making style. Finally, it will be critical to extend this research to examine behaviors related to health care decision making. There can be considerable mismatch between the roles patients say they want and the ones they feel they actually perform in the context of the health care visit (Ford, Schofield, & Hope, 2003
). Keeping these limitations in mind, we find that the WLS offers significant strengths as a large-scale, population-based cohort study that includes diverse information about respondents’ personal, health, social, and economic lives.
Respecting preferences for participation in health care decision making is an integral component of promoting optimal patient-centered care for older patients. Our results suggest that many factors, including multiple personality traits, gender, cognitive ability, rural or farm origins, education, and wealth, are associated with preferences for participation in health care decision making. We support the view that patient-centered care should strive to respond to individual patient’s needs and preferences when possible. This is not a novel concept, but we are still at the beginning of understanding when to encourage participation and when to respect patient preferences to not participate. For the majority of patients, the challenge lies in allowing them to participate to the extent they desire. For the smaller group who wants neither a lot of choices nor the role of making important medical decisions (the Nondeliberative Delegators), attempts to increase patient participation in decision making should be sensitive to those preferences. Rather than directed educational attempts to “retrain” patients by encouraging them to gain experience with decision making, it may be more sensitive to promote strategies to enhance the provider–patient relationship. The results of this study suggest that the length of a relationship with a specific health care provider is not related to patient decision-making style. However, enhancing continuity of health care and long-standing relationships with physicians may improve physicians’ ability to truly represent individual patients, when that is what is desired. Appreciation of how personality traits relate to patient decision-making styles may allow clinicians to individually tailor treatment discussions most appropriately, both to encourage participation and to respect preferences. This should continue to be explored in future research.