Department of Surgery, Division of Public Health Sciences, Washington University in St Louis School of Medicine, St Louis, MO, United States of America.
Dartmouth-Hitchcock Medical Center, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, United States of America.
PLoS One. 2021 Dec 16;16(12):e0260704. doi: 10.1371/journal.pone.0260704. eCollection 2021.
Shared decision-making is recommended for decisions with multiple reasonable options, yet clinicians often subtly or explicitly guide choices. Using purposive sampling, we performed a secondary analysis of 142 audio-recorded encounters between 13 surgeons and women eligible for breast-conserving surgery with radiation or mastectomy. We trained 9 surgeons in shared decision-making and provided them one of two conversation aids; 4 surgeons practiced as usual. Based on a published taxonomy of treatment recommendations (pronouncements, suggestions, proposals, offers, assertions), we examined how surgeons framed choices with patients. Many surgeons made assertions providing information and advice (usual care 71% vs. intervention 66%; p = 0.54). Some made strong pronouncements (usual care 51% vs. intervention 36%; p = .09). Few made proposals and offers, leaving the door open for deliberation (proposals usual care 21% vs. intervention 26%; p = 0.51; offers usual care 40% vs. intervention 40%; p = 0.98). Surgeons were significantly more likely to describe options as comparable when using a conversation aid, mentioning this in all intervention group encounters (usual care 64% vs. intervention 100%; p<0.001). Conversation aids can facilitate offers of comparable options, but other conversational actions can inhibit aspects of shared decision-making.
标题：共享决策在存在多种合理选择的决策中是被推荐的，但临床医生通常会微妙或明确地引导选择。
摘要：本研究通过目的抽样，对 13 名外科医生与有资格进行保乳放疗或乳房切除术的女性之间的 142 次音频记录的就诊进行了二次分析。我们对 9 名外科医生进行了共享决策培训，并为他们提供了两种对话辅助工具之一；4 名外科医生按照惯例进行实践。基于已发表的治疗建议分类（宣告、建议、提议、提供、断言），我们研究了外科医生如何与患者构建选择。许多外科医生做出断言，提供信息和建议（常规护理 71% vs. 干预 66%；p = 0.54）。一些医生做出了强烈的宣告（常规护理 51% vs. 干预 36%；p = 0.09）。很少有人提出建议和提议，为讨论留出余地（建议常规护理 21% vs. 干预 26%；p = 0.51；提议常规护理 40% vs. 干预 40%；p = 0.98）。使用对话辅助工具时，外科医生更有可能将选择描述为可比较的，在所有干预组的就诊中都提到了这一点（常规护理 64% vs. 干预 100%；p<0.001）。对话辅助工具可以促进可比选择的提供，但其他对话行为可能会抑制共享决策的某些方面。
