Stevenson F A, Barry C A, Britten N, Barber N, Bradley C P
Department of General Practice, University of Birmingham, Edgbaston, UK.
Soc Sci Med. 2000 Mar;50(6):829-40. doi: 10.1016/s0277-9536(99)00376-7.
The traditional paternalistic model of medical decision-making, in which doctors make decisions on behalf of their patients, has increasingly come to be seen as outdated. Moreover, the role of the patient in the consultation has been emphasised, notably through the adoption of 'patient-centred' strategies. Models that promote patients' active involvement in the decision-making process about treatment have been developed. We examine one particular model of shared decision making [Charles, C., Gafni, A., Whelan, T, 1997. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Social Science & Medicine 44, 681-692.]. The model has four main characteristics. These are that (1) both the patient and the doctor are involved, (2) both parties share information, (3) both parties take steps to build a consensus about the preferred treatment and (4) an agreement is reached on the treatment to implement. Focusing on the first two of the four characteristics of the model, we use the findings from a study of 62 consultations, together with interviews conducted with patients and general practitioners, to consider participation in the consultation in terms of sharing information about, and views of, medicines. We found little evidence that doctors and patients both participate in the consultation in this way. As a consequence there was no basis upon which to build a consensus about the preferred treatment and reach an agreement on which treatment to implement. Thus even the first two of the four conditions said to be necessary for shared decision making were not generally present in the consultations we studied. These findings were presented in feedback sessions with participating GPs, who identified a number of barriers to shared decision making, as well as expressing an interest in developing strategies to overcome these barriers.
传统的家长式医疗决策模式，即医生代表患者做出决策，已越来越被视为过时。此外，患者在诊疗过程中的作用得到了强调，特别是通过采用“以患者为中心”的策略。促进患者积极参与治疗决策过程的模式已经得到发展。我们研究一种特定的共同决策模式[查尔斯，C.，加夫尼，A.，惠兰，T，1997年。医疗诊疗中的共同决策：这意味着什么？（或至少需要两人共舞）。《社会科学与医学》44卷，681 - 692页。]。该模式有四个主要特点。即（1）患者和医生都参与其中，（2）双方共享信息，（3）双方采取措施就首选治疗达成共识，（4）就实施的治疗达成一致。聚焦于该模式四个特点中的前两个，我们利用对62次诊疗的研究结果，以及与患者和全科医生进行的访谈，从关于药物的信息共享及观点方面来考量诊疗中的参与情况。我们几乎没有发现证据表明医生和患者都以这种方式参与诊疗。因此，没有基础就首选治疗达成共识，也无法就实施何种治疗达成一致。所以，在我们研究的诊疗中，甚至共同决策所需的四个条件中的前两个通常都不存在。这些研究结果在与参与研究的全科医生的反馈会议上进行了汇报，他们指出了共同决策的一些障碍，同时也表达了对制定克服这些障碍策略的兴趣。
