Elwyn G, Edwards A, Gwyn R, Grol R
Department of Postgraduate Education for General Practice, University of Wales College of Medicine, Cardiff CF4 4XN.
BMJ. 1999 Sep 18;319(7212):753-6. doi: 10.1136/bmj.319.7212.753.
To explore the views of general practice registrars about involving patients in decisions and to assess the feasibility of using the shared decision making model by means of simulated general practice consultations.
Qualitative study based on focus group interviews.
General practice vocational training schemes in south Wales.
39 general practice registrars and eight course organisers (acting as observers) attended four sessions; three simulated patients attended each time.
After an introduction to the principles and suggested stages of shared decision making the registrars conducted and observed a series of consultations about choices of treatment with simulated patients using verbal, numerical, and graphical data formats. Reactions were elicited by using focus group interviews after each consultation and content analysis undertaken.
Registrars in general practice report not being trained in the skills required to involve patients in clinical decisions. They had a wide range of opinions about "involving patients in decisions," ranging from protective paternalism ("doctor knows best"), through enlightened self interest (lightening the load), to the potential rewards of a more egalitarian relationship with patients. The work points to three contextual precursors for the process: the availability of reliable information, appropriate timing of the decision making process, and the readiness of patients to accept an active role in their own management.
Sharing decisions entails sharing the uncertainties about the outcomes of medical processes and involves exposing the fact that data are often unavailable or not known; this can cause anxiety to both patient and clinician. Movement towards further patient involvement will depend on both the skills and the attitudes of professionals, and this work shows the steps that need to be taken if further progress is to be made in this direction.
探讨全科医学住院医师对于让患者参与决策的看法，并通过模拟全科医疗咨询来评估使用共同决策模型的可行性。
基于焦点小组访谈的定性研究。
南威尔士的全科医学职业培训计划。
39名全科医学住院医师和8名课程组织者（作为观察者）参加了4次会议；每次有3名模拟患者参与。
在介绍共同决策的原则和建议阶段后，住院医师与模拟患者就治疗选择进行了一系列咨询，并使用口头、数字和图形数据格式进行观察。每次咨询后通过焦点小组访谈引发反应并进行内容分析。
全科医学住院医师报告称未接受过让患者参与临床决策所需技能的培训。他们对“让患者参与决策”有广泛的看法，从保护性家长作风（“医生最了解情况”），到开明的自身利益（减轻负担），再到与患者建立更平等关系的潜在益处。这项工作指出了该过程的三个背景前提：可靠信息的可用性、决策过程的适当时间以及患者准备好在自身管理中发挥积极作用。
共享决策需要共享医疗过程结果的不确定性，并涉及揭示数据往往不可用或未知的事实；这可能会给患者和临床医生都带来焦虑。进一步让患者参与将取决于专业人员的技能和态度，这项工作展示了要在这个方向上取得进一步进展需要采取的步骤。
