Is there any encouragement for the patient to participate in the decision making process about his/her treatment? Do physicians act in a faith of concordance with their patients?
Hi Ehab,
This is an excellent question and one that is subject to much discussion. If you asked most physicians, they would probably respond that they do provide sufficient encouragement to patients, not only to participate in the decision-making process, but in following the treatment plan.
However, there is much literature that suggests that there is a very big gap between how effective physicians think they are in their communications with patients and how effective those communications truly are. There are many reasons for this "disconnect" in communication, or expectation. For example, there is literature pointing the a lack of physician "mindfullness" or active listening. On the patient side their is a lack of empowerment or self-efficacy, or self-agency, to actively engage in the decision-making process, follow the treatment plan, or communicate when there is a misunderstanding or lack of understanding.
Thus, this is not a one-sided issue in which the physician is to blame, or the patient is to blame. An appropriate approach would ensure that physicians are actively listening to what the patient says (and observe clues of what the patient doesn't say but really means), and to ensure that patients are actively engaged in the care process. This means that they ask questions when they are not 100% sure of what the physician means, and they seek out additional information to be able to have a more comprehensive discussion about treatment options. Finally, there needs to be a process to help a patient self-manage.
I'll stop here, and let others weigh in.
Ariel
Ariel has answered the second questions, but your first concern was adherence - and the concepts of health coaching are being taught in this workbook: http://www.healthchange.com/LiteratureRetrieve.aspx?ID=116478
From a legal standpoint this falls under something called 'informed refusal.' A physician makes a clear recommendation to the patient [to take a drug, to have a test, etc]. Should the patient not follow that recommendation it is the physician's duty to make sure the patient knows the risks and consequences of not following that advice. There are as many styles as physicians as to the emotional attachment a physician puts into encouraging a patient to anything. Above I've described the core [this is what I want you to do and these are the consequences if you don't do it]. As noted above non-compliance to some therapy is almost the rule.
Ehab, the most effective way to optimize adherence is to figure out what possible benefit of therapy is most salient to the patient, then connect that benefit strongly with the therapy itself.
For example, we may think the major benefit of an antihypertensive is to stabilize BP so as to reduce the risk of organ damage, whereas the pt may glom onto feeling less tired, fewer headaches or not having bothersome palpitations.
So over time a shrewd clinician will make note of benefits that many pts find salient before or after the fact, and infuse them succinctly into the rx discussion so as not to unwisely presume that the pt will internalize them from in-office measurement, labs or a package insert.
In particular, the stimuli for ongoing "re-evaluation" of the risk/benefit ratio for any therapy, all over the Internet and offline social interaction, demands that the "value proposition" be front and center in the pt's mind as an inoculation against stopping or stuttering the regimen.
These papers may be useful:
1. Storm, M., Hausken, K., and Mikkelsen, A. (2010), “User Involvement in In-patient Mental Health Services: Operationalization, Empirical Testing, and Validation,” Journal of Clinical Nursing 19, 13, 1897-1907.
2. Storm, M., Hausken, K., and Knudsen, K. (2011), “Inpatient Service Providers’ Perspectives on Service User Involvement in Norwegian Community Mental Health Centres,” International Journal of Social Psychiatry 57, 6, 551-563.
3. Storm, M., Knudsen, K., Davidson, L., Hausken, K., and Johannessen, J.O. (2011), “‘Service User Involvement In Practice’: The Evaluation of an Intervention Program for Service Providers and Inpatients in Norwegian Community Mental Health Centers,” Psychosis 3, 1, 29-40.
4. Heggland, L.H., Øgaard, T., Mikkelsen, A., and Hausken, K. (2012), “Patient Participation in Surgical Treatment Decision-Making from the Patients’ Perspective: Validation of an Instrument,” Nursing Research and Practice, Article ID 939675, 8 pages, doi:10.1155/2012/939675.
5. Heggland, L.H. and Hausken, K. (2013), “A Qualitative Identification of Categories of Patient Participation in Decision-Making by Healthcare Professionals and Patients During Surgical Treatment,” Clinical Nursing Research 22, 2, 206-227.
6. Heggland, L.H., Mikkelsen, A., and Hausken, K. (2013), “Models, Phases, and Cases of Patient Participation in Decision-Making in Surgical Treatment in Norway: A Qualitative Study,” Nursing and Health Sciences 15, 1, 39-44.
7. Heggland, L.H. and Hausken, K. (2014), “Patient Participation, Decision Makers, and Information Flow in Surgical Treatment,” Journal of Clinical Nursing 23, 9-10, 1430-1444.
8. Heggland, L.H., Mikkelsen, A., Øgaard, T., and Hausken, K. (2014), “Measuring Patient Participation in Surgical Treatment Decision-Making From Healthcare Professionals’ Perspective,” Journal of Clinical Nursing 23, 3, 482-491.
9. Heggland, L.H. and Hausken, K. (2015), “Four Categories of Patient Participation in Treatment and Their Linkage to Decision-Making in a Structure of 81 Models,” Nursing Reports 5, 4783, 1-12.
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