These results support several conclusions about the prevalence of physicians’ SDM behavior (as scored by OPTION) and factors affecting their use in the care of depressed patients in primary care settings. First, although health care professionals and researchers generally stress the importance of developing a clinical relationship in which patients and physicians share decision making (13
), most physicians did not attempt to involve patients to any great extent when providing depression care in this study. In addition, evidence from this study indicates that severity of depressive symptoms did not mitigate physicians’ SDM behavior, since there was no difference in SDM behavior between visits for major depression and adjustment disorder.
These results are consistent with the observations of Loh and colleagues, who found that physicians failed to engage fully in SDM during clinical encounters with depressed patients (8). Loh and colleagues reported that physicians seem to focus on the problem definition step, while failing to offer patients a variety of treatment options (8). A plausible explanation is that physicians sense – correctly or erroneously – that depressed patients are too sad or withdrawn to share decision-making during the initial visit. They may choose to treat first, and literally ask questions and involve patients later. In addition, physicians may simply not perceive that there are options; they may assume – correctly or incorrectly – that medication would be indicated, and that discussing small differences among medications is not good use of time.
Second, these findings provide insight into how physicians’ SDM behaviors are shaped and limited by external factors. Older physician age was associated with fewer SDM behaviors. This could reflect a cohort effect in which older physicians are more likely to subscribe to the “doctor knows best” philosophy. However, the more significant influence was whether or not the physician worked for a health maintenance organization (HMO). Contrary to previous work (7
), results from this study show that physicians working in an HMO practice setting made fewer attempts to involve patients in decision making processes than physicians in other settings. HMO physicians may be constrained by organizational factors such as formularies and treatment guidelines that hinder their ability to offer patients an extensive menu of treatment options. Time pressure, perceived or actual, also may hinder the performance of SDM behaviors (16
). It takes time to share information and preferences for treatments and negotiate a course of action, as indicated by the finding that greater SDM behavior was associated with longer visit duration.
Third, this study demonstrates experimentally that physicians’ SDM behaviors are influenced by patients’ requests for medication. When SPs initiated discussion about treatment options (i.e., treatment request), physicians responded with greater patient involvement. One interpretation of these results is that many physicians may approach patients with a paternalistic style by default and adopt more SDM behaviors only after the patient signals interest in SDM by acting assertively. Another possibility is that physicians, especially when interacting with new patients, begin with a neutral stance and use the initial minutes of the visit to sound out patients and determine how interested they might be in getting involved in their own care. If a patient indicates a high level of activation (e.g., by making a request), the physician might respond by invoking more SDM behaviors. These explanations are supported by the Interaction Adaptation theory, which posits that interactions between individuals involve mutual influence (17
). Physicians do generally support the idea of SDM, and will move toward this style when patients make an effort to participate in care.
These findings have implications for interventions designed to encourage SDM. For example, nurses or office staff may prompt patients to ask questions about treatment decisions following diagnoses, thus creating situations where patients and physicians subsequently may engage in SDM. Previous research shows that interventions can improve physicians’ involvement of patients in decision making activities (19
). However, these studies fail to address potential barriers to implementing SDM in practice, such as time constraints and perceived patient preferences (21
). Future research should create and test interventions to address barriers – including structural ones such as insufficient support from the organization (21
) – that may inhibit SDM.
This study has several limitations. First, only initial office visits were examined. SDM is a communication process that involves sharing information and preferences. This process may require longitudinal studies to fully understand how SDM evolves over time as the patient and physician become familiar with each other and develop a relationship. Second, while our reliance upon SPs allowed us to isolate experimentally the impact of patient activation on physician SDM behaviors, the tradeoff is the loss of some ecological validity. Further limiting generalizeability was that the SPs were all white, middle-aged, non-obese women. Patient-physician gender and race concordance may influence physicians’ behavior, a possibility we cannot address with these data. Third, we examined SDM within one context, depression care. This group of physicians might have demonstrated a greater level of shared decision-making had these patients presented with a different medical condition. Fourth, because our SPs were not truly depressed we are not in a position to link physician SDM behaviors to health outcomes. Fifth, there was low variance in half of the OPTION items. One possibility is that the extensive list of SDM behaviors identified in the instrument cannot be enacted (or may not necessarily be appropriate) in the typical primary care visit, owing to time constraints. For example, it may be possible that the OPTION instrument (and the implied model of SDM) is better adapted to single-event, high-stakes or irreversible decisions (such as choosing mastectomy vs. lumpectomy for breast cancer) in which there is sufficient time for discussion, rather than more evolving and reversible decisions which occur in a time-pressured primary care environment.
In summary, we found that primary care physicians performed few SDM behaviors when evaluating a patient with depressive symptoms. Furthermore, practice characteristics appear to affect physicians’ levels of SDM, suggesting that physician SDM behaviors are influenced by the organizational context. But to their credit, physicians did move toward SDM when patients signaled a desire for it by making treatment requests. Future research should focus on training patients to become active participants in treatment decision-making to improve the quality of care through negotiated decisions, and developing practice strategies that allow for the efficient sharing of power in the clinical relationship. The benefits of doing so may include increased patient adherence and satisfaction, as well as improved health outcomes (4