BackgroundOlder patients differ from younger patients in their perceptions of trust in doctors; their sense of shared decision making is particularly associated with their trust in the GP. Enhancing trust and improving shared decision making are thought to have positive health outcomes. Older patients are sometimes reported as being less frequently involved in decisions about their health care, however, and in having more unmet healthcare needs than younger patients.
AimThis study explored older patients' trust in their GPs and their perceptions of shared decision making.
Design and settingQualitative methods were used. Systematic sampling identified 20 participants, aged ≥65 years, from three GP surgeries in Devon, UK.
Background: Shared decision-making, utilising the expertise of both patient and clinician, is a key feature of good-quality patient care. Multimorbidity can complicate shared decision-making, yet few studies have explored this dynamic for older patients with multimorbidity in general practice. Aim: To explore factors influencing shared decision-making from the perspectives of older patients with multimorbidity and GPs, to inform improvements in personalised care. Design & setting: Qualitative study. General practices (rural and urban) in Devon, England. Method: Four focus groups, two with patients (aged 65+ with multimorbidity) and two with GPs. Data were coded inductively by two researchers applying thematic analysis. Results: Patient acknowledgement of clinician medicolegal vulnerability in the context of multimorbidity, and their recognition of this as a barrier to shared decision-making, is a new finding. Medicolegal vulnerability was a unifying theme for other reported barriers to shared decision-making. These included expectations for GPs to follow clinical guidelines, challenges encountered in applying guidelines and in communicating clinical uncertainty, and limited clinician self-efficacy for shared decision-making. Increasing consultation duration and improving continuity were viewed as facilitators. Conclusion: Clinician perceptions of medicolegal vulnerability are recognised by both patients and GPs as a barrier to shared decision-making and should be addressed to optimise delivery of personalised care. Greater awareness of multimorbidity guidelines is needed. Educating clinicians in the communication of uncertainty should be a core component of shared decision-making training. The incorrect perception that most clinicians already effectively facilitate shared decision-making should be addressed to improve the uptake of personalised care interventions.
Background: Although shared decision-making (SDM) is key to delivering patient-centred care, there are barriers to general practitioners (GPs) implementing SDM in practice. SDM training is undergoing development by organisations, including the Royal College of General Practitioners. However, GPs’ perceptions of the delivery of SDM training in general practice remain largely unexplored. Aim: To explore GPs’ perceptions of teaching methods in SDM training. Design and Setting: A qualitative study of GPs with teaching roles at the University of Exeter Medical School was conducted. Method: Purposive sampling recruited 14 GPs. Semi-structured interviews explored their SDM educational experiences. Data were analysed using thematic framework analysis. Results: Three themes were identified. The GPs described role-play, receiving feedback, and on-the-job learning as modes of delivering SDM training that positively informed their SDM in clinical practice. Learning from knowledgeable individuals and using realistic patient cases were perceived as beneficial components of SDM learning, though most learning occurred implicitly through reflections on their clinical experiences. The GPs identified the incorporation of the uncertainty that is present in general practice consultations; targeting of individual GPs’ SDM learning needs and explanation of the potential benefits of SDM on consultation outcomes as important methods to facilitate the implementation of SDM in practice. Conclusion: This is the first UK study to explore GPs’ perceptions of SDM training and provide recommendations for practice. As SDM occurs in partnership with patients, further research should obtain and incorporate patients' views alongside those of GPs in the evaluation of future programmes.
Background
The number of older people with multiple health problems is increasing worldwide. This creates a strain on clinicians and the health service when delivering clinical care to this patient group, who themselves carry a large treatment burden. Despite shared decision-making being acknowledged by healthcare organisations as a priority feature of clinical care, older patients with multimorbidity are less often involved in decision-making when compared with younger patients, with some evidence suggesting associated health inequalities. Interventions aimed at facilitating shared decision-making between doctors and patients are outdated in their assessments of today’s older patient population who need support in prioritising complex care needs in order to maximise quality of life and day-to-day function.
Aims
To undertake feasibility testing of an intervention (‘VOLITION’) aimed at facilitating the involvement of older patients with more than one long-term health problem in shared decision-making about their healthcare during GP consultations.
To inform the design of a fully powered trial to assess intervention effectiveness.
Methods
This study is a cluster randomised controlled feasibility trial with qualitative process evaluation interviews. Participants are patients, aged 65 years and above with more than one long-term health problem (multimorbidity), and the GPs that they consult with. This study aims to recruit 6 GP practices, 18 GPs and 180 patients. The intervention comprises two components: (i) a half-day training workshop for GPs in shared decision-making; and (ii) a leaflet for patients that facilitate their engagement with shared decision-making. Intervention implementation will take 2 weeks (to complete delivery of both patient and GP components), and follow-up duration will be 12 weeks (from index consultation and commencement of data collection to final case note review and process evaluation interview). The trial will run from 01/01/20 to 31/01/21; 1 year 31 days.
Discussion
Shared decision-making for older people with multimorbidity in general practice is under-researched. Emerging clinical guidelines advise a patient-centred approach, to reduce treatment burden and focus on quality of life alongside disease control. The systematic development, testing and evaluation of an intervention is warranted and timely. This study will test the feasibility of implementing a new intervention in UK general practice for future evaluation as a part of routine care.
Trial registration
CLINICAL TRIALS.GOV registration number NCT03786315, registered 24/12/18
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.