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Time to Get Back to Basics

Clarence H. Braddock III, MD, MPH; Kelly A. Edwards, MA; Nicole M. Hasenberg, MPH; Tracy L. Laidley, MD, MPH; Wendy Levinson, MD

JAMA. 1999;282:2313-2320.

Context  Many clinicians have called for an increased emphasis on the patient's role in clinical decision making. However, little is known about the extent to which physicians foster patient involvement in decision making, particularly in routine office practice.

Objective  To characterize the nature and completeness of informed decision making in routine office visits of both primary care physicians and surgeons.

Design  Cross-sectional descriptive evaluation of audiotaped office visits during 1993.

Setting and Participants  A total of 1057 encounters among 59 primary care physicians (general internists and family practitioners) and 65 general and orthopedic surgeons; 2 to 12 patients were recruited from each physician's community-based private office.

Main Outcome Measures  Analysis of audiotaped patient-physician discussions for elements of informed decision making, using criteria that varied with the level of decision complexity: basic (eg, laboratory test), intermediate (eg, new medication), or complex (eg, procedure). Criteria for basic decisions included discussion of the nature of the decision and asking the patient to voice a preference; other categories had criteria that were progressively more stringent.

Results  The 1057 audiotaped encounters contained 3552 clinical decisions. Overall, 9.0% of decisions met our definition of completeness for informed decision making. Basic decisions were most often completely informed (17.2%), while no intermediate decisions were completely informed, and only 1 (0.5%) complex decision was completely informed. Among the elements of informed decision making, discussion of the nature of the intervention occurred most frequently (71%) and assessment of patient understanding least frequently (1.5%).

Conclusions  Informed decision making among this group of primary care physicians and surgeons was often incomplete. This deficit was present even when criteria for informed decision making were tailored to expect less extensive discussion for decisions of lower complexity. These findings signal the need for efforts to encourage informed decision making in clinical practice.

Author Affiliations: Departments of Medicine (Dr Braddock), Health Services (Dr Braddock), and Medical History and Ethics (Dr Braddock and Ms Edwards), University of Washington, Seattle, and Health Services Research and Development Field Program, VA Puget Sound Health Care System (Dr Braddock and Ms Hasenberg), Seattle, Wash; Cascade Physicians, Portland, Ore (Dr Laidley); and the Division of General Internal Medicine and Geriatrics, University of Chicago, Chicago, Ill (Dr Levinson). Dr Laidley was formerly with the Department of Medicine, University of Washington, and the Health Services Research and Development Field Program, VA Puget Sound Health Care System.

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