Jacobse Sofie, Rijkels-Otters Hanneke, Eikens-Jansen Manon, van der Weijden Trudy, Elwyn Glyn, van den Broek Walter, Bindels Patrick, Zwaan Laura
Department of General Practice, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands.
Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands.
Eur J Gen Pract. 2025 Dec;31(1):2501302. doi: 10.1080/13814788.2025.2501302. Epub 2025 Jun 2.
Shared decision-making (SDM) is considered the preferred communication model, yet its applicability in the diagnostic process is understudied.
To identify clinical situations in the diagnostic process that could benefit from SDM.
An observational study of closed malpractice claims against general practitioners (2012-2020) related to problems of diagnosis, obtained from a liability insurance company in the Netherlands. We established SDM-selection criteria, specified for the diagnostic process (i.e. diagnostic uncertainty, multiple options and clinical equipoise). Phase 1: We selected and categorised eligible cases, using summarised information from a claim database. Phase 2: We analysed 90 fully documented claims and extracted information from GPs and patients related to the diagnostic process. Using this data, we conducted an inductive thematic analysis.
Phase 1: 261 out of 1477 claims (18%) met the SDM-selection criteria. The main reason for complaints was (omitted) test-ordering (155 claims, 59.4%). The most frequent final diagnoses were: fracture (49%), malignancy (10%), infection (9%), tendon rupture (8%) and cardiovascular disease (4%). Phase 2: Six types of diagnostic considerations emerged from the data: diagnostic uncertainty, using time as a diagnostic tool, management consequences, information about test indication or procedure, indications for re-evaluation and individual patient context. Contradictory statements from GPs and patients demonstrated a lack of shared understanding.
The diagnostic process could benefit from SDM in several areas, including discussing diagnostic options, test conditions (e.g. timing and procedure) and follow-up. SDM training programs should be tailored to encourage clinicians to apply SDM in diagnostic decisions.
共同决策(SDM)被认为是首选的沟通模式,但其在诊断过程中的适用性研究不足。
确定诊断过程中可从共同决策中受益的临床情况。
对荷兰一家责任保险公司提供的2012年至2020年针对全科医生的已结案医疗事故索赔进行观察性研究,这些索赔与诊断问题相关。我们制定了针对诊断过程的共同决策选择标准(即诊断不确定性、多种选择和临床平衡)。第1阶段:我们使用索赔数据库中的汇总信息选择并分类符合条件的病例。第2阶段:我们分析了90份有完整记录的索赔,并从全科医生和患者那里提取了与诊断过程相关的信息。利用这些数据,我们进行了归纳主题分析。
第1阶段:1477份索赔中有261份(18%)符合共同决策选择标准。投诉的主要原因是(省略)检查医嘱(155份索赔,59.4%)。最常见的最终诊断为:骨折(49%)、恶性肿瘤(10%)、感染(9%)、肌腱断裂(8%)和心血管疾病(4%)。第2阶段:数据中出现了六种类型的诊断考虑因素:诊断不确定性、将时间用作诊断工具、管理后果、关于检查指征或程序的信息、重新评估指征以及患者个体情况。全科医生和患者的矛盾陈述表明缺乏共同理解。
诊断过程在几个方面可从共同决策中受益,包括讨论诊断选项、检查条件(如时间和程序)以及后续跟进。共同决策培训项目应进行调整,以鼓励临床医生在诊断决策中应用共同决策。