Barriers to the evidence-based patient choice (EBPC) consultation
Introduction
The theory of ‘evidence-based patient choice’ (EBPC) brings together two important modern movements in western health care namely evidence-based medicine (EBM), and patient-centred care [1]. Traditionally, EBM and patient-centred medicine have belonged to separate worlds. However, bridging the gap between these two paradigms has been described as a major challenge for all who want to protect the humane face of medicine in the next millennium [2]. The call for the integration of EBM and patient-centred care is partly a response to the fact that medical practice is increasingly being dominated by scientific evidence that potentially bypasses patients’ own preferences and values. In the medical consultation, EBPC means providing patients with evidence-based information in a way that facilitates their ability to make choices or decisions about their health care. By combining EBM with patient-centred care, information that is of value and personal importance to patients is considered in parallel with scientific evidence-based information as part of the decision-making process.
EBPC is one of several models in existence which advocates providing patients with the necessary information to enable them to become involved in decisions about their care [3], [4], [5], [6], [7]. The move towards increasing patient involvement is driven by a theoretical concern for respect for patient autonomy [8]. This emphasises that patients should be in a position to choose whether to accept an intervention or not as part of their general right to determine their own lives. Specifically, EBPC recognises the fact that individuals differ both in what they value and in their propensity to take risks [1].
The concept of shared decision-making between doctors and patients is an area of considerable debate, both in terms of the principles and competencies involved. The traditional paternalistic model of medical decision-making has largely become seen as anachronistic. However, there is still relatively little known about the desire of patients to have a role in medical decision-making. Empirical evidence (reviewed by Stewart) [9] suggests that giving patients information and involving them in decisions about their health care can result in beneficial psychological, physical and physiological outcomes, but there is a dearth of studies on the varying needs of different patient groups [10]. Along side this, there is a growing consensus that sharing medical decisions is justifiable on humanistic grounds alone [11].
Currently, opinions differ on the competencies required and the conditions necessary for shared decision-making to occur. For example, the exploration of patient preferences for information and involvement in decision-making are common preliminary stages in some models [4], [7]. However, some commentators [6] posit that it is illogical to ask about a patient’s preferred role in decision-making until they have information concerning the possible harms and benefits of the choices they face. Only when armed with this information will patients be in a position to decide what is best for them. Gwyn and Elwyn also suggest that not all medical encounters lend themselves to a shared approach. For example, decisions concerning the use of antibiotics to treat viral disorders are more likely to be informed decisions, in line with the doctor’s preference. Therefore, a situation of equipoise where several effective options exist must be present in order for a shared decision to successfully take place [12].
Barriers to shared decision-making and EBM have previously been investigated in empirical studies. Reasons why general practitioners (GPs) do not engage in shared decision-making include: lack of time; other organisational pressures; the belief that patients lack the will or ability to participate in shared decision-making [13]; and lack of skills needed by doctors to involve patients in clinical decision-making [6]. EBM is commonly criticised for being doctor-centred, in that it focuses on the doctor’s interpretation of evidence and diminishes the importance of human relationships and the role of the patient in the consultation [14]. However, it can be argued that the term ‘evidence-based’ is becoming outdated as consensus grows that EBM should acknowledge multiple dimensions of evidence including practical evidence based on individuals’ interpretation of experience [15]. There is a demand for a new definition of EBM that includes evidence produced outside science [16].
This qualitative study explores informed opinion concerning the perceived obstacles to achieving a successful EBPC consultation. We stress that we were testing reactions to the concept rather than to the actual existence of the EBPC consultation. As part of a larger study to investigate the elements and skills required for a successful EBPC consultation, a series of semi-structured interviews were carried out with key informants. We deliberately selected a range of knowledgeable and highly motivated participants, many of whom we considered to be well informed about the debates concerning EBM and patient-centred care. This was to acquire informed opinion on the feasibility of EBPC working in practice.
Section snippets
Participants and methods
Purposive sampling was used to recruit participants who were anticipated to have an interest in issues relating to shared decision-making, EBM and patient-centred care. We wanted to tap into the opinions of professionals with an understanding of these concepts. Those invited to take part included 12 GPs, 12 hospital doctors, 12 academics, 10 lay persons and 10 nurse practitioners. GPs and hospital doctors were chosen from a list of medical student tutors all of whom were known to the authors.
Results
Those who agreed to participate included 11 GPs, (n=3 women), 10 hospital consultants (n=4 women), 11 academics (n=7 women), eight lay persons (n=1 male) and five nurse practitioners, all of whom were women. In total, 45 respondents were entered into the analysis, 26 being women. Six main themes emerged from the data and these are presented in Table 1.
Discussion
If progress is to be made towards patient empowerment it will be important to identify the various barriers to its implementation as a preliminary to trying to overcome them. We have sought to do this through a systematic qualitative study of the barriers to one specific model of patient empowerment, EBPC. Several of the barriers identified are being addressed, whereas others have received less attention.
Some of the drawbacks expressed in relation to the evidence accord with previous studies,
Acknowledgements
We thank all those who gave up their time to be interviewed and our colleagues who gave advice throughout the study, in particular Professor Paul Salkovskis and Joyanne McInnes. This paper forms part of a project funded by the NHS Anglia and Oxfordshire Regional R&D.
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