Management reasoning and patient-clinician interactions: Insights from shared decision-making and simulated outpatient encounters

Abstract

Purpose

To expand understanding of patient-clinician interactions in management reasoning.

Methods

We reviewed 10 videos of simulated patient-clinician encounters to identify instances of problematic and successful communication, then reviewed the videos again through the lens of two models of shared decision-making (SDM): an ‘involvement-focused’ model and a ‘problem-focused’ model. Using constant comparative qualitative analysis we explored the connections between these patient-clinician interactions and management reasoning.

Results

Problems in patient-clinician interactions included failures to: encourage patient autonomy; invite the patient’s involvement in decision-making; convey the health impact of the problem; explore and address concerns and questions; explore the context of decision-making (including patient preferences); meet the patient where they are; integrate situational preferences and priorities; offer >1 viable option; work with the patient to solve a problem of mutual concern; explicitly agree to a final care plan; and build the patient-clinician relationship. Clinicians’ ‘management scripts‘ varied along a continuum of prioritizing clinician vs patient needs. Patients also have their own cognitive scripts that guide their interactions with clinicians. The involvement-focused and problem-focused SDM models illuminated distinct, complementary issues.

Conclusions

Management reasoning is a deliberative interaction occurring in the space between individuals. Juxtaposing management reasoning alongside SDM generated numerous insights.

Keywords:

• Decision Making
• shared
• clinical decision-making
• communication
• diagnostic reasoning
• therapeutic reasoning

Acknowledgments

We thank Larry D. Gruppen, PhD, for his assistance in initial (phase 1, stage 1) video review and analysis.

Ethical approval

The study used to develop videos was judged exempt by Mayo Clinic Institutional Review Board (06-002730). No new human subjects were enrolled as part of this study.

Disclaimer

The views expressed herein are those of the authors and not necessarily those of the Department of Defense or other federal agencies.

Author contributions

All authors contributed to the conception and design and the acquisition, analysis, or interpretation of data. All authors had full access to all data. All contributed to drafting and revising the manuscript, and approved the final manuscript. All agree to be accountable for all aspects of the work.

Disclosure statement

The authors report there are no competing interests to declare.

Glossary

Management reasoning: The cognitive processes by which clinicians integrate clinical information (history, exam findings, and test results), preferences, medical knowledge, and contextual (situational) factors to make decisions about the management of an individual patient, including decisions about treatment, further testing, follow-up encounters, and allocation of limited resources.

Management script: Precompiled conceptual knowledge structures that represent and connect management options and clinician tasks in a temporal or logical sequence to facilitate development of a rational management plan.

Purposeful shared decision-making: A novel model for shared decision-making that recognizes that many clinical situations do not entail choosing among options so much as clarifying desires, solving problems, or addressing existential issues of humanity and identity. Viewed through this lens, the primary purpose of SDM is not to "involve" patients in decision-making, but to establish methods for working together that are appropriate for this patient’s particular problems.

Box 1 Proposed best practices for enhancing management reasoning through shared decision-making.

• Allow autonomy and choice

  • … in defining the goal (problem)

  • … in negotiating / selecting the management plan (solution)

• Invite participation

  • … in defining the goal (problem)

  • … in guiding the conversation (pathway)

  • … in negotiating / selecting the management plan (solution)

• Define the right problem

  • … and make it relevant to the patient (e.g. impact on health, lifestyle, and identity, not just lab value or treatment goal)

• Find out (ascertain, inquire) preferences, values, resources, constraints

• Meet the patient where they are

• Address underlying concerns, fears, questions

• Integrate problems, comorbidities, priorities, preferences, resources, and other contextual factors

  • … jointly with the patient

• Build the relationship

  • … a mediator to effective SDM in involvement-focused model

  • … a product of effective SDM in problem-solving model

• Reason together in the space between clinician and patient

  • … endeavor together to solve a problem

• Create meaning: explain and explicitly link the problem and solution

  • … easier when relevance of problem has been explicated (see above)

• Directly answer questions

• Offer >1 viable option

  • … and include option to do nothing

• Commit to an agreed-upon decision (don’t defer decision simply to avoid effortful negotiation)

Note: Many of these ‘best practices’ represent the inverse of the empirical observation (i.e. we observed a failure to follow this practice, and from that failure we inferred an action to avoid it).

Additional information

Funding

Internal grant from the Division of General Internal Medicine, Mayo Clinic, Rochester, MN. There was no external funding.

Notes on contributors

David A. Cook

Dr. David A. Cook is Professor of Medicine and Professor of Medical Education; Director of Education Science, Office of Applied Scholarship and Education Science; and Consultant in the Division of General Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.

Ian G. Hargraves

Dr. Ian G. Hargraves is Assistant Professor of Medicine; researcher with the Knowledge and Encounter Research Unit; and Director of Design at the Mayo Clinic National Shared Decision Making Resource Center, Mayo Clinic, Rochester, Minnesota, USA.

Christopher R. Stephenson

Dr. Christopher R. Stephenson is Assistant Professor of Medicine and Consultant in the Division of General Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.

Steven J. Durning

Dr. Steven J. Durning is Professor and Vice-Chair of Medicine and Director, Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.