Shared decision making in orthopaedics: mind the gap

SDM is the approach in which patients and physicians use the best available
evidence to make an agreed decision. It promotes involvement of the patient
within the medical consultation and encourages both patient and physician to
think about possible treatment options. SDM is especially suitable for
conditions in which there is no absolute choice of treatment, such as
osteoarthritis, degenerative spinal disorders, and cruciate ligament injury, so
that medical treatment could be aligned with the preferences of patients. When
SDM is applied, up to 38% less joint replacement surgeries are performed. SDM
could, therefore, not only reduce healthcare costs, but also prevent
unnecessary treatment. Moreover, it improves (health) outcomes after surgical
and non-surgical treatment.

Effective SDM consists ideally of four steps: 1) choice talk: the physician
informs patients about their choice in the decision, 2) option talk: the
physician explains and elaborates on the different treatment options, 3-4)
option talk: the patients' preferences will be discussed and the decision will
be made. One of the key characteristics of SDM is that physician and patient
share information and take steps to come to a consensus about the treatment
plan (including no treatment/wait and see). Patients and physicians thus need
information as well as the ability to make the decision. Ideally, physicians
have information about cultural issues, illness perceptions and language, and
know what the preferences and expectations of patients are, to provide them
with adequate information in order for the patient to make an informed
decision. However, a gap in the medical consultation exists; the patient
perspective largely remains unexplored and SDM is not commonly employed.
Patient involvement in the medical consultation is usually low and expectations
are rarely explicitly discussed within the physicians* office. The minority
(i.e. 11-25%) of patients present all their concerns and worries about the
diagnosis, the future, or side effects. Most patients do not voice their
agendas without being asked to and they often neglect to ask for information,
clarification, or explanation. In fact, only 10% of patients discuss all the
things they would like to mention during consultation.

An asymmetry exists in the interaction within the medical consultation, which
poses a barrier to SDM. Physicians are often the ones to propose and ask
questions, which are often framed in a way that only allows short answers and
inhibit questions asked by patients. This fits the assumption that the medical
consultation partly serves to objectively explain and educate the patient,
which is mostly focused on a biomedical view. Reasoning for questioning is not
provided by physicians, resulting in a gap in given information for the
patient. Answers to statements of patients, used by physicians, as *okay*,
which lack judgment about the answer of patients, additionally leads the
patient in the dark. Furthermore, involvement of patients remains low by a
so-called *context stripping* approach; medical consultations rarely focus on
subjective experiences and personal perceptions, such as expectations.
Moreover, patients do not disclose their expectations due to false beliefs
about the purpose of the medical consultation. Physicians pay little attention
to the perceptions of the patient and therefore hardly ask about them.
Orthopedic physicians are rated low in communication skills. Hardly half of the
concerns of orthopedic patients are addressed by the physician during
consultation. Additionally, time constraints and the organizational structure
of the general clinical situation are also proposed as barriers for SDM.

Thus, the literature indicates a gap between patients and physicians in the
medical consultation. Nonetheless, it is not known how the above-mentioned gap
in doctor-patient communication is related to the exploration of the patients'
perspective and the use of SDM. Moreover, it is unknown why physicians
construct their consultations the way they do and it is unclear why patients
neglect to express their perspective. Obstructing and facilitating factors of
effective doctor-patient communication, therefore, should be examined in order
to
be able to close the gap in doctor-patient communication and stimulate the use
of SDM.

a. Primary Objective:
To examine the (barriers and facilitators of) the current use of SDM in
doctor-patient communication, we will explore the communication practices
(verbal and nonverbal) used by physicians and patients.

Research questions:
1) What is the current use of SDM within different orthopedic patient
populations?
2) Which factors within verbal communication, nonverbal communication, and
general interactional patterns during consultation hinder of facilitate the
exploration of the patient perspective?
3) To what extent did the medical consultation change during this study due to
discussion or reflection upon communication practices?

Given the literature, we expect that SDM is not yet fully implemented in
clinical practice. The time constraint of medical consultations, but also the
fact that physicians need time to discuss the possible complications could
sometimes lead to situations that SDM was not optimal. We expect that the
scientific approach in real life situations will result in practical solutions,
of which some can be and will be immediately implemented in clinical practice.

This study has a multimethod design in which (i) the doctor-patient
consultation will be videotaped and analyzed and (ii) interviews will be held
with patients and physicians. As the interviews could have an impact on future
medical consultations, this study, in addition to being a prospective
observational study, could possibly be seen as an experimental study examining
the effects of discussing and reflecting on the medical consultation. We aim to
include all consecutive patients of the Elisabeth-TweeSteden Hospital with
osteoarthritis, degenerative spinal disorders, and cruciate ligament injury,
until the required sample size has been met.

Time Period: 18 months
Part 1: video- and audio-recording of consultations (month 1-5). After the
first recording is performed, we immediately start with the analyses.
Transcription and analyses of recordings (month 1-9)
Part 2: interviews with patients and physicians (month 10-14), second wave of
recordings of medical consultations (month 15-17)
Part 3: examining the effect of the discussion and reflection of the medical
consultation on the interaction in future consultations (month 16-18)

Subjects can leave the study at any time for any reason if they wish to do so
without any consequences. The investigator can decide to withdraw a subject
from the study for urgent medical reasons.

Patients will be videotaped during the doctor-patient consultation and
participate in an interview regarding the doctor-patient consultation, so there
is no risk in participating in the study. Patients receive care as usual. If
patients think that they, for any reason, are not ready to answer questions
about their physical condition, communication practices or any of the other
variables of interest, they are free to refuse participation or to not answer
specific items. They are able to notify the researchers at any given time
during the study that they want to stop participation, in which case their data
will be withdrawn. Patients participating in this study do not directly
benefit.
However, the study will provide insight in the current use of SDM and how
doctor-patient communication could facilitate or hinder the implementation of
SDM. ln this study real-life consultations are analyzed, allowing exploration
of practical issues of clinical practice. Our conclusions will, therefore be
relevant for practicing clinicians striving to achieve SDM. The study results
provide information on whether and/or how to adapt future medical
consultations. Our conclusions will, therefore be relevant for practicing
clinicians striving to achieve SDM. lt is expected that the part, in which
surgeons reflect on their communication strategies, will already change the way
consultations are performed. Moreover, in September 2019 the NIAZ visits the
ETZ hospital. One of the topics that will be assessed is 'patient
participation'. ln this study, patients will provide feedback upon
communication practices.