We started from the top of a randomised list of the 380 videos to get an overall impression, and studied encounters without any particular coding structure in mind. To contrast the medical perspective, we included a social psychologist/communication specialist (RMF) in the analytic phase of the study. The team had a continuous dialogue about the potential biases generated by a shared medical perspective. Informed by previous medical training, we had no problem with understanding the words and actions observed in the encounters. The four-member project team consisted of a specialist registrar in internal medicine/research fellow (EHO), a neurologist/professor (JCF), a general practitioner/professor (ES) and a professor of health services research/previously a general practitioner and a public health specialist (PG). We assembled a team of physicians to analyse the videotaped encounters starting autumn 2010. Such a taxonomy could be helpful in teaching, and in studies on quality of medical work, its financial implications, understanding of patient involvement, and disentangling the complexity of physicians’ everyday tasks. This paper describes the process from initial observations of video recorded patient–physician encounters, through deliberations about what constitutes a decision, to the development of a taxonomy of decisions. In order to better understand clinical decision-making processes, we aimed to identify and classify all decisions emerging in conversations between patients and physicians. The literature lacks a comprehensive system for classifying medical decisions in patient–physician encounters. 14 Most of the time, diagnostic problem-solving and therapeutic actions present options that require decision-making and leave room for interpretation because of medical and contextual complexity. However, medical ‘problem-solving’ often involves ‘decision-making’ on the path to a conclusion, best illustrated by the fact that diagnostic conclusions seldom reveal themselves they have to be produced by someone. However, it does not capture decisions that influence the subsequent ‘courses of action’, such as evaluations of findings and tests, and interpretations concerning diagnosis, prognosis and aetiology, most likely because patient involvement in such decisions is not considered relevant.ĭeber 13 made a distinction between ‘problem-solving’, which was defined as the ‘search for a single correct solution to a problem, and ‘decision-making’, which was defined as ‘situations in which a choice must be made among one of several alternatives’. This definition is broad and includes actions leading to diagnostic tests, prescriptions, referrals and instructions regarding diet and physical activity. In a study of patient involvement in decisions, Braddock et al 12 developed a descriptive definition of a medical decision as ‘a verbal statement committing to a particular course of action’. Haynes et al 11 have pointed out that this is a prescriptive rather than descriptive approach to medical decisions: ‘It is a guide for thinking about how decisions should be made rather than a schema for how they are made’.Ĭlinical encounters often deal with multiple problems, with several decisions being made. For example, Sackett et al 10 define evidence-based decisions as ‘the integration of best research evidence with clinical expertise and patient values’. 1 Attempts to define decisions have followed these function-specific patterns. 1 4–9 Medical decision science has descriptive, normative and prescriptive functions: explaining how patients and physicians routinely make decisions, proposing standards for ideal decision-making, and providing tools to make good decisions in practice, respectively. The words decision and judgement are used as synonyms in everyday and medical language, 3 which is reflected in the research and theory on clinical judgement and decision-making that have advanced healthcare in the past five decades. 1 Decision-making can be regarded as the cognitive process resulting in the selection of a belief or a course of action among several alternative possibilities. Decision-making is a key activity in patient–physician encounters, with decisions as the outcomes of such activity.
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