The issue
Shared decision-making is a widespread ideal across the National Health Service (NHS) in Great Britain and in many other healthcare settings. But studies repeatedly show that doctors and nurses struggle to enact this ideal in practice.
This matters because patients report wanting to be more involved in deciding about their care and there is good evidence that they do better when they are. Better communication skills are key. However, conventional training has been criticised - by medics themselves - for not being specific enough to equip them for the complexities of real conversations with patients.
The research
Communication has been a focus of research in Sociology at York for over four decades. A recent project, externally funded by the NIHR, explored how doctors made decisions with patients in over 200 real-time neurology consultations.
We identified two effective ways in which doctors offered patients a choice. However, we found that doctors were much more likely to make recommendations for what they thought was best. When they did so, patients were significantly more likely to end up accepting the recommended course of action than when a choice was offered. This implies a dilemma for doctors: on the one hand, NHS policy has emphasised the need to increase patient choice since at least 2000; on the other hand, clinical guidelines may show that one treatment is best.
We argue that doctors need to be aware of the advantages and risks of different approaches to decision-making in order to balance their duty of care with their responsibility to empower patients to make their own decisions.
The outcome
Making decisions with patients is not easy. Doctors and nurses benefit from specific communication training, grounded in how decision-making works in practice. Our research identified effective communication skills and produced a rich evidence base of recorded consultations. We have used this to produce innovative in-person and online training for medical staff and students. This has reached across numerous medical specialties in the NHS and in Brazil, the Netherlands and Norway. Our findings have been included in medical school curricula and by the UK’s National Institute for Health and Care Excellence (NICE) in their training on how to implement shared decision-making.
Related research in the Sociology Department on decision-making in midwife-led maternity units also shows that policy initiatives emphasising patient involvement are challenging to enact in practice. It has found that women are afforded limited optionality in decision-making, and that midwives orient to guidelines/standard clinical practice in pursuing particular decisional outcomes. We are currently working with the Royal College of Midwives’ Progress Theatre Group to disseminate these findings.
For more about our research on patient choice in practice, see:
- Delivering patient choice in clinical practice: a conversation analytic study of communication practices used in neurology clinics to involve patients in decision-making
- Evaluating nuanced practices for initiating decision making in neurology clinics
- Interactional practices of decision making during childbirth in maternity units
- The NICE shared decision-making guidance
- Request access to our elearning package on patient choice.
