Social Science & Medicine 56 (2003) 589602

What are the ingredients for a successful evidence-based patient choice consultation?: A qualitative study
Sarah Ford*, Theo Schoeld, Tony Hope
The Ethox Centre, Institute of Health Sciences, University of Oxford, Old Road, Headington, Oxford OX3 7LF, UK

Abstract The evidence-based patient choice (EBPC) approach is one of a number of newly emerging templates for medical encounters that advocate evidence-informed choice and shared decision-making. These models emphasise respect for patient preferences for involvement in health care decisions and advocate the sharing of good quality evidence-based information. In the medical consultation EBPC involves providing patients with evidence-based information in a way that facilitates their ability to make choices or decisions about their health care. Whereas the key principles of shared decision-making have been conceptualised, so far, no qualitative investigations have been undertaken to establish the key components of an EBPC consultation. Therefore, a series of semi-structured interviews were carried out with key informants to identify the elements and skills required for a successful EBPC consultation to occur. The interviews were conducted with purposively selected UK general practitioners (n 11), hospital doctors (n 10), practice nurses (n 5), academics (n 11) and lay people (n 8). Qualitative analysis of participants responses was conducted using the constant comparative method. Six main themes emerged from the data, these were research evidence/medical information, the doctorpatient relationship, patient perspectives, decision-making processes, time issues and establishing the patients problem. All respondents placed importance on doctors and patients being well informed and appraised of the latest available medical evidence. There was a general view that evidence-based information regarding diagnosis and treatment options should be shared with patients during a consultation. However, there were no suggestions as to how this might be achieved in practice. Participants opinions relating to which model of decisionmaking should be adopted ranged from favouring an informed choice model, to the view that decision-making should be shared equally. Similarly, there was no clear view on how much guidance a doctor should offer a patient during decision-making concerning the most appropriate treatment option for that patient. r 2002 Elsevier Science Ltd. All rights reserved.
Keywords: Evidence-based medicine; Patient-centred care; Shared decision-making

Introduction The term evidence-based patient choice (EBPC) was rst described by Hope (1996) as the merging together of two important modern movements in western health care, namely evidence-based medicine and patient-centred care. This approach is one of several newly emerging models of the medical encounter which advocate evidence informed patient choice (Entwistle,
*Corresponding author. Tel.: +44-1865-227049; fax: +441865-226938. E-mail address: sarah.ford@ethox.ox.ac.uk (S. Ford).

Sheldon, Sowden, & Watt, 1998; Towle & Godolphin, 1999) and shared decision-making (Braddock, Edwards, Hasenberg, Laidley, & Levinson, 1999; Charles, Gafni, & Whelan, 1999; Elwyn, Edwards, Kinnersley, & Grol, 2000). EBPC is not limited to what has been termed the neglected second half of the consultation (Elwyn, Edwards, & Kinnersley, 1999), like most other approaches it encompasses the whole consultation of which an important component is patient involvement in decision-making. Evidenced-based medicine (EBM) requires the use of current best evidence to make decisions about the care of individual patients (Sackett, Straus, Richardson,

0277-9536/03/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 0 2 ) 0 0 0 5 6 - 4

590

S. Ford et al. / Social Science & Medicine 56 (2003) 589602

Rosenberg, & Haynes, 2000). Clinical interventions are recommended on the strength of evidence for their effectiveness derived mostly from randomised-controlled trials and systematic reviews. Five basic tenets of EBM have been identied: 1. clinical decisions should be based on the best available scientic evidence, 2. the clinical problem determines the evidence to be sought, 3. identifying the best evidence involves epidemiological and biostatistical ways of thinking, 4. conclusions based on the available evidence are useful only if put into action for individual patients or for population health care decisions, 5. performance should be constantly evaluated (Davidoff, Haynes, Sackett, & Smith, 1995). However, in this biomedical approach the individual qualities, needs and preferences of patients have tended to be neglected as relevant factors in the decisionmaking process (Bensing, 2000). Whilst, EBM addresses the biomedical perspective of diagnosis, mostly from a doctor-centred paradigm (Jacobson, Edwards, Granier, & Butler, 1997), doctors also need evidence that is derived from a patient-centred paradigm that takes into account the personal and contextual elements of decision-making in practice. Patient-centred medicine, is derived from a humanistic, biopsychosocial perspective and combines ethical values on the ideal doctor, with psychotherapeutic theories on the facilitation of patients disclosure of concerns and negotiation theories on decision-making (Bensing, 2000). This model of care places a strong emphasis on patient participation in clinical decision-making by taking into account the patients needs and preferences. Therefore, in order for cognitively competent patients to have the power to make evidence-based choices, as well as being evidencebased, the medical consultation must be patientcentred. Providing patients with evidence-based knowledge should enhance their power and aid the development of an increasingly effective patient-centred health care system (Hope, 1996). However, there is a need to ensure that evidence-based information is conveyed to patients in a way that will increase their understanding and enable them to make informed choices about their treatment and management. In the medical consultation, evidence-based patient choice requires providing patients with good quality information to facilitate their ability to make choices or decisions about their health care. The original theory combines evidence-based medicine with patient-centred care, so that information that is of value and personal importance to patients when making choices (e.g. process of delivery of care) is considered in parallel with scientic evidence-based information. However, the term evidence-based is

increasingly becoming outdated as consensus grows that EBM should acknowledge multiple dimensions of evidence including practical evidence based on individuals interpretation of experience (Buetow & Kenealy, 2000). Therefore, evidence-based patient choice must embrace a broader denition of EBM that includes evidence produced outside science. The origins of patient choice The concept of patient choice originates from the doctrine of informed consent. In English and US law a competent person has a legal right to refuse treatment (even life saving). Valid consent is achieved only if the individual concerned has been given the relevant information. Over the last 20 years, medical ethicists have stressed the importance of the principle of patient autonomy (Veatch, 1982; Brody, 1985; Dworkin, 1988; Quill & Brody, 1996). This emphasises that patients should be in a position to choose whether to accept an intervention or not as part of their general right to determine their own lives (Hope, 1996). A central ethical principle behind evidence-based patient choice is that the information is being given in order to enhance choice. Patient choice goes beyond consent and involves the patient in the decision-making process. However, the move towards increasing patient involvement is not driven simply by a theoretical concern for respect for patient autonomy. Rather, it is a recognition of the fact that individuals differ both in what they value and in their propensity to take risks (Hope, 1996). Trends in Western health care Models of shared decision-making and EBPC reect a growing trend in health care towards patient empowerment and greater patient choice (Department of Health, 2000). This has been fostered by the increasing patient access to information about treatments and the consumerist trends in modern society (Ballard-Reisch, 1993; Elwyn et al., 1999). Over the last 20 years or so there has been a call for more patient choice and personal control in medical care (Reiser, 1993). Current National Health Service (NHS) initiatives advocate active partnerships between health professionals and patients (NHS Executive, 1996) and the improvement of information to help patients choose between options (NHS Executive, 1995). Nowadays, most theorists acknowledge that unilateral decision-making by doctors is unacceptable (except in certain situations, for example, when a patient is comatose or in urgent need of life-saving action). The old paternalistic models of doctorpatient relations have been rejected by policy makers, and medical academics in favour of more equitable and collaborative relationships characterised by informed choice. There is a

S. Ford et al. / Social Science & Medicine 56 (2003) 589602

591

growing consensus that sharing decisions is desirable on humanistic grounds alone (Guadagnoli & Ward, 1998). Benets of involving patients There is also empirical evidence that giving patients information and involving them in decisions about their health care can result in benecial psychological and physical outcomes. For example, enhanced patient satisfaction Roter (1983), adherence to treatment plans (Janis, 1982), greater condence in health care recommendations (Brody, 1980), psychological adjustment to illness (Falloweld, Hall, Maguire, & Baum, 1990) and symptom resolution (Bass et al., 1986). It has also been found that if patients are actively involved in making decisions about their care, physiological outcomes such as diabetic control can be improved (Greeneld, Kaplan, Ware, Yano, & Frank, 1988). Further evidence suggests that allowing patients to choose their medical treatment can enhance psychological well-being (Ashcroft, Leinster, & Slade, 1986; Falloweld et al., 1990, 1994). In her comprehensive review of health outcomes, Stewart (1995) concluded that four key dimensions of communication were related to positive patient outcomes (emotional health, symptom resolution, function and physiological health):
* * * *

including those of a psychological, physiological and nancial nature. Patient preferences for evidence-based information Little is known about patients preferences for evidence-based information during consultations. The limited work in this area suggests that for some conditions, the majority of patients value being given information about the effectiveness of treatment and care options (Wagner, Barrett, Barry, Barlow, & Fowler 1995). Inevitably patient preferences are increasingly being inuenced by the consumerist trends in modern society which, in turn, have fostered better access to medical information. Developments in Britain such as local consumer health information services (Sheppard, Charnock, & Gann, 1999) have improved awareness of, and access to, evidence-based consumer health information. More recently, innovations such as the recently launched National Electronic Library for Health (NeLH) (Muir Gray & de Lusignan, 1999), now provide health professionals and patients with easy access to the most up-to-date evidence of the effectiveness of healthcare interventions. Not surprisingly, patients are becoming increasingly better informed about health care issues and expect to be given comprehensive information concerning their diagnosis, prognosis and treatment options (Jenkins et al., 2001). Patient involvement in health care Despite the current trends that advocate greater patient involvement in health care, whether patients actually want this is yet to be conclusively demonstrated. For example, Savage and Armstrong (1990) conducted a study involving 359 randomly selected patients consulting with one general practitioner to compare the effect of directing and sharing styles of consultation on patient satisfaction. The authors found that patients in the directive group with self-limiting problems or chronic conditions and those receiving a prescription, reported signicantly higher levels of satisfaction on several outcome measures. These included: satisfaction with the GPs perceived understanding of their problem and the explanation they received. The results of a study investigating Australian, UK and US preferences for participation in medical decision-making suggested that mutuality was the preferred method of decision-making for participants in all 3 countries (Smith, Garko, Bennett, Irwin, & Schoeld, 1994). The authors found that if the question was asked, Do patients prefer to decide for themselves or delegate decisions to their doctors? participants chose to delegate, but if respondents were asked if they preferred joint decision-making, delegating or deciding they preferred joint decisions.

the provision of clear information, questions from the patient, willingness to share (discuss) decisions, agreement between patient and doctor about the problem and the plan.

There is also evidence that giving patients information about the choices open to them can sometimes lead to fewer prescriptions for specic drugs such as warfarin (Protheroe, Fahey, Montgomery, & Peters, 2000) and less demand for some surgical treatments as in the case of benign prostatic hyperplasia (Barry, Fowler, Mulley, Henderson, & Wennberg, 1995). However, there are other studies that show that although patients prefer patient-centred care, it does not necessarily enhance physiological outcome. For example Kinmonth, Woodcock, Grifn, Spiegal, & Campbell (1998) carried out an intervention study to assess the effect of additional training of practice nurses and GPs (for abbreviation see Fig. 1) in patient-centred care on outcomes of patients with newly diagnosed type 2 diabetes. In this study patients in the intervention group reported better communication with doctors, greater treatment satisfaction and wellbeing than the comparison group. However, their body mass index was signicantly higher as were triglyceride concentrations. There is a clear need for more robust studies to investigate the effects of patient involvement in different disease groups on a variety of health care outcomes,

592

S. Ford et al. / Social Science & Medicine 56 (2003) 589602

Most of the empirical research evaluating patient preferences for participation has been conducted in North America using high stake scenarios, for example, decisions concerning treatment for cancer. Therefore, it is not known whether these ndings can be applied to other patient populations and different medical contexts, such as patients in general practice. Much of the research is based on surveys using different assessment measures which makes comparisons difcult (Deber, 1994a, b; Guadagnoli & Ward, 1998). Studies conducted using hypothetical questions or contrived scenarios may not truly reect patients preferences during a real clinical interview. The desire to be involved (or not) in decision-making may depend on the type and severity of a patients condition. For example, Beaver et al. (1996) surveyed 150 women recently diagnosed with breast cancer using a role-preference card-sort (Degner & Sloan, 1992) which consisted of ve cards with a written statement and cartoon depicting increasing levels of patient involvement. The women were asked to choose their preferred decision-making role from all possible pairings of the ve cards (ten in total). Results showed that 20% wanted an active role in deciding their treatment, 28% preferred a joint decision, and just over half (52%) wanted their surgeon to decide for them. In contrast a control group of patients with benign breast disease wanted to share responsibility for decision-making with the surgeon. The cancer patients were assessed at an early stage and had no denite knowledge about their type of cancer, prognosis or treatment. Therefore, this lack of information may have contributed to their reluctance to be more involved in the decision-making process. In an extension of the above study (Beaver, Bogg, & Luker, 1999) a comparison of the decisionmaking preferences and information needs of colorectal (n 48) versus breast cancer patients (n 150) was conducted. Once again a decisional role preference card sort was used and an information needs questionnaire. It was found that the majority (78%) of the colorectal patients preferred to play a passive role in decisionmaking, in contrast to 52% of the breast cancer patients. Of note is the fact that both groups had similar information needs relating to cure, spread of disease and treatment options. The majority of patients desire for information is stronger than their desire to be involved in decision-making (Ende, Kazis, Ash, & Moskowitz, 1989; Strull, Lo, & Charles, 1984; Degner et al., 1997; Beaver et al., 1999). Furthermore, many patients would like to receive more information than they currently do from health care professionals (Audit Commission, 1993; Meredith et al., 1996). Whether they wish to be involved in decision-making or not, patients increasingly expect to be told their diagnosis and details concerning pathophysiology, treatment

options and prognosis (Laine & Davidoff, 1996; Meredith et al., 1996). The purpose of this qualitative study was to identify the elements and skills required for a successful EBPC consultation to occur. We stress that we were testing reactions to a theoretical concept rather than to the actual existence of the EBPC consultation. The key principles of shared decision-making have already been conceptualised (Charles et al., 1997; Towle & Godolphin, 1999). However, no qualitative investigations have yet been undertaken to establish the key components of an EBPC consultation. Therefore, a series of semi-structured interviews were carried out with key informants in an attempt to establish these criteria.

Methods and sample Purposeful sampling was used to recruit participants who were anticipated to be good informants, i.e., those likely to have an interest in patient involvement in decision-making, evidence-based medicine and patientcentred care. Those invited to take part included UK general practitioners, hospital doctors, academics, lay people and nurse practitioners. The GPs and hospital doctors were medical student tutors afliated to the UK Oxford medical communication skills teaching programme. Academics were established commentators on patient involvement in health care. Lay people were recruited through the Oxfordshire Community Health Council and had keen interests in issues connected with patient empowerment. Nurse practitioners were selected from the surgeries of participating GPs. All potential participants received a letter which included basic information about the concept of EBPC and which invited them to take part in semi-structured interviews. The explanation of EBPC was presented as follows:In the medical consultation, EBPC means providing patients with evidence-based information to enable them to make choices or decisions about their health care. By combining evidence-based medicine with patient-centred care, information that is of value and personal importance to patients is considered in parallel with scientic evidence-based information as part of the decision-making process. We would like your views on the elements and skills needed for EBPC to take place in the medical consultation. Those who were willing to take part received a preinterview prompt sheet one week before being interviewed. This was to enable them to familiarise themselves with the concept of evidence-based patient choice and make notes on the implications of this approach.

S. Ford et al. / Social Science & Medicine 56 (2003) 589602

593

Eleven GPs (3 of whom were women) agreed to take part and 10 hospital consultants (4 of whom were women). Participating academics (4 of whom were parttime GPs) numbered 11 (7 of whom were women). Eight lay people agreed to be interviewed (1 of whom was a male) and 5 nurse practitioners all of whom were women. In total, the responses of 45 interviewees were included in the qualitative analysis, 26 of whom were women. The semi-structured interviews, which were audiotaped, took place at respondents place of work except for the lay people, most of whom were interviewed in their own homes. At the start of each interview the researcher explored respondents personal understanding of the concept of EBPC. Interviewees were then asked their opinion on the key components (including skills) needed for a successful EBPC medical consultation to occur in practice.

responses concerning the meaning of EBPC shown in Fig. 1. Fig. 2 shows the 6 main themes that emerged from the data. These are presented below in order of importance, according to the numbers of respondents and responses within each one. The categories drawn from each theme are outlined in Table 1. Due to the exploratory nature of this study there are considerable overlaps between some of the categories and these are emphasised.

Research evidence/medical information All respondents placed importance on doctors being well informed and appraised of the latest available medical evidence. It was also considered desirable for doctors to have fast and easy access to reliable sources of evidence, e.g. an NHS desk-top computer link to the latest research evidence. Related to this, a need was identied for doctors to be trained in computerised data retrieval and to attend training courses on how to practice evidence-based medicine. Critical appraisal skills were considered necessary for doctors to enable them to nd the correct evidence, interpret it, appraise its limitations and apply it appropriately. It was important for patients to have access to good sources of evidence, e.g. a reliable internet source. There was a feeling particularly from academics and lay people that the quality of written patient information and internet health sites was generally poor and required some form of quality control. Good quality evidence for use by doctors was dened in terms of needing to be reliable, up-to-date, accurate and comprehensible. This evidence was considered to stem mostly from randomised clinical trials and evidence-based guidelines. Other sources of evidence such as patient experience of care and illness were also acknowledged, particularly by lay people and academics. There was a general view that evidence-based information regarding diagnosis and treatment options must be shared with patients during a consultation. Patients should expect to be informed/educated about the nature of their illnesses/problems and be directed by the doctor to other sources of information relevant to the diagnosis. Treatment options were considered best given in accordance with the strength of the evidence and choices clearly identied including the option of no treatment. Fundamental was a description of the processes, risks/side effects, benets, possible outcomes and chances of success for each option. The importance of honesty was emphasised mostly by academics and lay people in the context of options, some of which might not be available on the NHS, and the description of risks and side effects associated with each treatment alternative. The sharing of information by doctors included giving patients graphical representations of

Analysis and coding The interviews were analysed using the constant comparison method, a qualitative technique which involves the systematic sifting and comparison of items of recorded data to reveal and establish the mutual relationships and internal structure of categories (Green, 1998). Responses were transcribed and divided into simpler text units that were entered into a database for ease of coding. Units of text (at least one complete thought) referring to similar issues were separated from dissimilar units and systematically grouped together by one coder. Each grouping represented a provisional theme. When all the text units had been coded into the emergent categories these were tested by being reapplied by an independent coder. The level of agreement between the coders for these preliminary codes was 88%. A series of discussions were held and reorganisation of some of the data took place, before the nal codes were agreed.

Results Overall, participants had a clear understanding of the theoretical principles behind evidence-based patient choice, but perhaps unsurprisingly, were less clear about the specic processes that might be involved to achieve it during a medical consultation. Furthermore, GPs and hospital doctors in particular were rather sceptical about the successful application of this model in practice. This scepticism was reinforced by the expression of several types of barriers to the implementation of this approach (reported elsewhere, Ford, Schoeld, & Hope, 2001). This general nding is exemplied by the selection of

594

S. Ford et al. / Social Science & Medicine 56 (2003) 589602

"Well I think it's a fairly utopian concept {yeah} but how actual how pragmatic and realistic it is um I'm probably less sure of {hmm}. I think probably thinking about it, whilst it's an ideal and I think we should always try and achieve ideals and aim high {hmm}. The trouble is that I think the single biggest restraint on it is time and pressure {yeah} and I think its the type of thing which in an ideal circumstance whereby you had very long consultations with patients and very small numbers of patients to sort of look after and devote much more time to them and their queries then it's something that can be achieved {hmm}; but, the um but there's a problem at the coal face, of the you know of the NHS in trying to get that done {yeah}." [GP 5] "Um well given that they have a choice there must be at least two ways of approaching management um and I guess what we do in the simplest form is say we can either do nothing or we can give you this treatment , if we do nothing we know from experience this is what will happen {hmn} . If we give you this treatment we think it will make it better or we know it will make it better and in it's simplest form it's based on the clinician's interpretation of the available evidence in very simple forms and impressions {ahuh} but and I think that's how it works currently {yes}. There's obviously enormous potential for elaborating that {hmn}, but I have I'm sure some patients would welcome that, but I have to say a lot of patients particularly in my field when we've tried that just switch off, don't listen, don't want to know and if we go into it in any detail become uncertain um and nervous and full of doubts ." [HD 4] "Well I think two things, one is the evidence um .. and the other is patient choice, I think that um evidence should be available, I mean first of all as far as is possible clinical decisions should be based on evidence .. um .. and that means that the evidence has to be available both to the doctor and to the patient and sometimes to the patients carers as well - there may be other people involved and there may be more than one clinician involved um but ideally decisions should be informed by the evidence, I don't think they're necessarily driven by the evidence {ahuh} because the evidence is usually incomplete {ahuh} so they should be informed by it {yes}." [AC 1] "For me it means giving the patient the opportunity to discuss choices of treatment {yup} and then being able to make an informed decision giving the patient information about treatment and medication which has a scientific track record. This means assessing criteria for different types of treatment whether it's based on a surgical option or a drug based option {ahuh}, and this would mean that for any patient who has any sort of problem um I think if it has been tried and tested and it has worked for other people {hmm} that's also nice to know. I can think of examples like arthritis and other sorts of conditions where there are lots of sorts of options, lots of sorts of drugs and even possibly surgery for when it's really bad {yeah}, but I think again a patient sitting there would like to have some information about well what's happened in the past - has somebody tried this {yes} and has it worked, would it work if I had an operation and things like that having some kind of proof as to whether something works or not." [LP 3] "It means trying to present to patients what the evidence is for their problem and listening to their concerns and giving them time to discuss all the options, but at the end of the day it is down to the patient to make that decision {yes}. Um for example, I work a lot with students and one of the things is the new introduction of a new emergency contraception {hmm}, you know and that has huge costing implications {yes}, but you need to discuss with them the benefits of it, the research that has been shown and advising them in that respect {yeah}." [PN 4]

Key: GP = General practitioner, HD = Hospital Doctor, AC = Academic, LP = Lay Person, PN = Practice Nurse

Fig. 1. What does evidence-based patient choice mean to you? (interviewer) (Note: the interviewers speech appears in curly brackets).

the evidence, which could aid comprehension, and providing written evidence-based information about treatment alternatives. Three academics, 1 GP and 1 hospital doctor suggested that decision aids and/or written information should be available to help patients decide which option would be best for them. Thirty ve respondents mentioned ability to convey complex information as being an essential skill for the EBPC consultation. There was a strong belief that a doctor should have the exibility to adjust the amount

and type of information according to a patients level of need and understanding. One GP stated that it was important not to overload the patient with information and another insisted that facts and gures should not dominate the consultation process. The nal category derived from this theme involves just under half of the total number of respondents. It concerns tting or tailoring the evidence to the patient in question. This was perceived not just in medical terms, but also involved taking into account the views,

S. Ford et al. / Social Science & Medicine 56 (2003) 589602

595

Establishing nature of the problem

Patients' Perspectives

Doctor-Patient Relationship

Responses from 45 interviewees

Research Evidence/ Medical Information

Decision Making Process

Time Issues

Fig. 2. Main themes from analysis of elements of a successful EBPC consultation.

preferences and personal circumstances of the individual patient. For example: You need to apply the evidence to the patient as a person not just a disease. [HD11] A doctor needs to apply the evidence according to the patient as an individual. [AC3]

Doctorpatient relationship The general characteristics of the doctorpatient relationship concerned issues, which ideally should be present in any doctorpatient encounter such as trust, respect, honesty and partnership building. These issues were mentioned by the majority of respondents in each group, exemplied by the following statements: There should be openness and trust between a doctor and a patient. [NP5] The patient should be treated as an individual and an equal partner. [GP5] The relationship between a doctor and a patient should be built up on mutual trust. [LP3] As with the general characteristics of the doctor patient relationship, it was felt by respondents that doctors should have effective communication and relationship building skills whatever the type of consultation. Therefore, the skills stated are not specically those necessary for an EBPC consultation, but could

apply to most doctorpatient encounters. These are displayed in Table 2, Section 1. The most frequently mentioned skill was the ability to listen. Listening to patients was seen as a basic skill to enable assessment of the language that patients use in order to pitch information level and to encourage discussion by listening to patients views without interruption. Lay people in particular felt that doctors had a tendency to interrupt and talk over patients. Two respondents felt that listening was also desirable for patients: patients can help doctors by listening and asking questions when they do not understand. [LP5] you need to have a sensible patient who listens and retains information. [HD11]

Patients perspective Forty two respondents made at least one comment which related to issues concerning the patients perspective. Responses related mostly to exploring patients individual qualities and circumstances. Gaining an understanding of the patients perspective during a consultation involved exploration and consideration of expectations, assumptions, anxieties, concerns, beliefs and values. This was linked to elicitation of the patients agenda and establishing patient ideas and level of knowledge concerning the illness and possible courses of action. Several lay

596

S. Ford et al. / Social Science & Medicine 56 (2003) 589602

Table 1 Main themes and associated categories Theme Research evidence/medical information Category Access to & knowledge of the evidenceFdoctor needs fast and easy access to the evidence. Doctor must be well informed of the latest research data; patients also need access to the latest medical evidence e.g. reliable internet site. QualityFthe evidence must be of good quality (i.e. up-to-date, accurate; reliable; comprehensible) for doctors and patients. Appraisal and InterpretationFdoctor must be able to critically appraise evidence in order to interpret and apply it correctly. Sharing the evidenceFeducating patient about the condition; guiding him/her to other sources of information relevant to the diagnosis. Description of the evidence for different treatment options including implications of no treatment, risks and benets. Information-giving skillsFability to: convey/translate complex Information re: evidence/ options; tailor information to patients needs; convey non-directive information, etc. Fitting the evidence to the patientFdoctor must tailor the evidence/options to the patient in question taking into account his/her views, values, preferences and personal circumstances. General characteristicsFequal partnership, mutual respect, honesty, openness and trust between both parties; maintenance of privacy and condentiality, etc. Interpersonal skills of doctorFlistening, negotiation, cue recognition (verbal and non), use of open and reective questions, eye contact, ability to put patients at ease, empathy and appropriate reassurance, non-directive style, etc. Personal attributes required by doctorFattitude conducive to practising this type of approach, energy, motivation, condence, approachability, sensitivity, etc. Practical issues/settingFenvironment conducive to uninhibited communication; continuity of care (seeing the same doctor), etc. Exploration and consideration of patients perspectivesFexpectations, prior beliefs, anxieties and concerns, etc. Patient preferences for information and involvementFspecically information concerning medical condition/treatment options and level of involvement desired in decision-making process Model of decision-makingFinformed choice, shared decision, etc. Pre-decision deliberationFallowing patient time to consider and discuss the options; deferring decision if necessary, etc. Decision aids/written informationFthese should be available to help patient decide which option Level of doctor guidance versus patient autonomy Post-decision tasksFtime may be needed to reect on why and how the decision was made; follow-up arranged if necessary, etc. Time needed to seek out evidence Time needed to discuss options with patients Obtaining full story from patient Enabling Patients to tell their own stories

Doctorpatient relationship

Patients perspectives

Decision-making process

Time issues Establishing nature of problem

people emphasised the importance of the acknowledgement by doctors that patients bring certain personal qualities to the consultation. For example: Doctors should acknowledge that patients bring knowledge to the consultationFthey have life experiences. [LP1] The doctor needs to understand that patients have hopes and fears which often become acute when illness is an issue. [LE5] Allied to patient perspectives were preferences for information and involvement in decision-making. There

were strong views that the doctor must ascertain how much and at what level a patient wants to receive information concerning the medical problem and treatment options. Related to this, it was felt that patients should have the choice not to be presented with evidence and should only be given the information they want and not given details they dont want. Similarly, ascertaining how much involvement patients would like in the nal decision-making process was seen as desirable to enable involvement for those that want it. It was frequently stated by hospital doctors and GPs that the preferences of patients who wanted little or no involvement in decision-making should be

S. Ford et al. / Social Science & Medicine 56 (2003) 589602 Table 2 EBPC consultation skills (1) General Communication and relationship building skills Use of open and reective questioning techniques Use of good eye contact Letting the patient set the pace Listening skills Picking up on patients emotional cues and non-verbal clues Summarising Clarifying skills Orienting the patient Putting patients at ease Conducting the consultation without clock watching or rushing the patient Building up a good rapport Use of appropriate reassurance (2) Skills required for evidence-based shared decision-making Ability to communicate complex information using nontechnical language; Tailoring the amount and pace of information to the patients needs/preferences; Drawing diagrams to aid patient comprehension; Checking patient understanding Ability to weigh up medical evidence about treatment options whilst considering the values of the patient; Conveyance of objective, non-directive information regarding possible options; Explanation of probability and risk for each option; Facilitative skills to encourage patient involvement; Evaluation of internet information that patients might bring with them; Creation of an environment whereby patients feel able to ask questions Negotiation skills

597

A joint management plan should be worked towards. [GP12] If possible decision-making should be shared. [GP8] Ideally, there should be a partnership approach to decision-making. [LE1] There should be a shared discussion of alternatives resulting in a decisions as to the best option for the patient. [LE7] Patients should be encouraged to be part of decisionmaking if desired. [PN3] Commonly mentioned terms were negotiation, shared and joint. There was overall agreement that patients should be given the opportunity to be involved in the nal decision-making process if that was what they desired. Pre-decision deliberations included allowing patients time to take in and consider the information; and providing an opportunity to discuss the choices. There was general agreement that doctors should help patients reect on and assess the impact of alternative decisions with regard to their individual circumstances, values and lifestyle. Several academics felt that patients should be able to defer a decision and attend for another appointment if necessary. Responses relating to level of doctor guidance versus patient autonomy were concerned with how much input a doctor should have (compared to the patient) after the options had been discussed, but before a decision had been made. Responses ranged from: y the doctor should steer the patient in the direction of the most appropriate option [HD9] to y need to allow the patient the level of freedom they need in order to decide on a course of action [GP12]. It was noticeable that hospital doctors tended to frown upon providing all the options and then expecting patients to decide which one was best for them. The majority felt that doctors should advise patients on the best course of action for them. On the other hand, lay people tended to state that doctors should give an opinion as to which treatment would be the most appropriate, but the patient should have the right to reject this. There were two academics who raised the issue of scientic equipoise, i.e. when there is more than one equally effective treatment option. One felt that equipoise should be declared in order to legitimise patient involvement in decision-making and the other felt it was important for a doctor to state if patient choice was arising from a position of scientic equipoise. Post-decision tasks involved giving patients time to reect on why and how the decision was made and

respected; whereas academics and lay people tended to emphasise respect for a patients nal choice of treatment.

Decision-making process Responses concerning the decision-making process were divided into 4 categories relating to: model of decision-making, pre-decision deliberations, level of doctor guidance versus patient autonomy and postdecision tasks. Thirty ve respondents made at least 1 comment for this theme. A range of descriptors was used to describe the ideal model for deciding the appropriate treatment for a patient. For example: The patient must be given the chance to make an informed choice if he or she wants to. [AC9] A treatment decision should be negotiated between doctor and patient. [AC2]

598

S. Ford et al. / Social Science & Medicine 56 (2003) 589602

eliciting their understanding of the rationale behind the decision. It was viewed as being important to arrange a follow-up visit to check on patients progress and reconsider the decision if necessary. This was commonly referred to as an opportunity for more in-put on both sides. It was stated by over two thirds of respondents that doctors require certain abilities and skills in order to achieve an evidence-based shared decision (Table 2, Section 2). Some of these skills overlap with the information-giving skills previously cited under the research evidence theme.

Time issues Overwhelmingly, it was considered important to have enough time to practice the EBPC approach. In particular, plenty of time is needed during the consultation to nd and discuss the evidence. It was also felt that a doctor should be willing to see a patient on more than one occasion to discuss the evidence and options. One GP said: ideally consultation length should not be an issue as patients need time to talk and ask questions about options. Another lay expert believed that patients could spend a little time preparing for the consultation beforehand.

Establishing nature of the problem This theme was the smallest in terms of the number of contributing respondents. This may be because it was taken for granted that the primary purpose of the doctor during any consultation is to ascertain the patients reason for attending. At least 1 member of each response group is represented. GPs responses predominate followed by those of hospital doctors. A common response concerned obtaining the full story from the patient in conjunction with checking family history, background and social circumstances. Lay people felt it important to let patients describe the problem in their own words. One hospital doctor emphasised eliciting psychosocial in addition to medical details and information about the patient as an individual. There was a clear view that the current problem must be clearly formulated.

Discussion The analysis of 45 semi-structured interviews brought to light 6 main themes relating to the essential ingredients for an EBPC consultation (see Fig. 2). Some categories were difcult to delineate and as a result there is some overlap between some of the themes. For

example, recurrent responses running through several themes were the importance of eliciting the patients perspective and good communication skills for the health professional. The elicitation of the patients values is a precursor of the decision-making process and is necessary before applying evidence. The patients perspective is also salient when attempting to establish the nature of the problem. Similarly, sharing evidencebased information is a prerequisite for shared decisionmaking, which in turn requires the health professional to have the ability to convey complex medical information. Therefore, our 6 identied themes are far from concrete and very much open to further interpretation. Furthermore, participants tended to compartmentalise their responses so that these related either to the patientcentred elements of EBPC or the evidence-based medicine components, but they struggled to join the two parts of the model together in any depth. Consequently, much of the framework that emerged is in keeping with a patient-centred model of the consultation and evidence-based medicine rather than specically EBPC. This is an indication that respondents found it difcult to consider or had no clear idea of how EBPC could work in reality. Undoubtedly, this reects the problematic nature of dening this type of theoretical approach in practice and this should be borne in mind when considering the results. An important theme in terms of number of responses was research evidence/medical information. This concerned doctors and patients having the skills to access and gain knowledge of good quality evidence. Information giving skills were needed by doctors to share the evidence with patients and educate them about their condition. Fitting the evidence to the patient was also an important component whereby the patients preferences and personal circumstances are taken into account in addition to medical criteria. However, recent research indicates that many doctors are not in touch with the evidence-base. For example, in a recent a survey of 302 English GPs (McColl, Smith, White, & Field, 1998) there was a reluctance to acquire the necessary critical appraisal skills needed in order to track down, assess and apply evidence to patients. Similarly, Mayer & Piterman (1999) found that out of the 27 GPS they surveyed, none expressed a need for critical appraisal skills. In McColl and colleagues survey (1998), only 20% of GPs had access to Medline or other bibliographic databases and 17% had access to the world wide web. Doctors are not the only individuals who need access to good quality medical evidence. Patients also need good quality health information to enable them to become more involved in their medical care. However, recent studies of patient information materials and internet health information have found that few sources meet patients information needs in terms of presenting

S. Ford et al. / Social Science & Medicine 56 (2003) 589602

599

information about the range of relevant treatment options, and providing a non-biased, evidence-based view of the effectiveness of each treatment (Coulter, Entwistle, & Gilbert, 1998; Sacchetti, Zvara, & Plante, 1999; McKinley, Cattermole, & Oliver, 1999). Communication skills were viewed as particularly important in relation to sharing the evidenceFspecically the ability to interpret complex information for patients. The information sharing stage of a consultation if it contains probabilistic data is termed risk communication (Elwyn et al., 1999). The development of risk communication tools for a course on shared decision-making has revealed some of the difculties in portraying the risks and benets of commonly encountered problems (Edwards, Elwyn, & Gwyn, 1999). Improved ways of communicating risk to patients and the acquisition of communication skills conducive to evidence-based patient choice are needed to take this approach forward. Exploring patient preferences for information and involvement in decision-making are common stages in models of shared decision-making (Charles et al. (1997); Entwistle et al. (1998); Towle & Godolphin, 1999; Braddock et al., 1999). For some patients the right not to receive information is an important part of their care and should be respected (Laine & Davidoff, 1996). Elwyn, Edwards, and Kinnersley (1999) argue that it is illogical to ask about a patients preferred role in decision-making until they have information concerning the possible harms and benets of the choices they face. Only when they are armed with this information will they be in a position to decide what is best for them. The majority of patients have a desire for more information about their illness and treatment options, but only a small number appear to express a preference to participate in treatment decisions. More research is needed to investigate the reasons behind these ndings. The doctorpatient relationship was viewed as an important element of the EBPC consultation. General characteristics included mutual respect, honesty and trust between both parties. Interpersonal skills were key to the maintenance of a good relationship between doctor and patient. These included listening, recognising verbal and non-verbal cues, putting patients at ease, empathy and appropriate reassurance. Basic interviewing skills can be learned at undergraduate and postgraduate level, providing effective methods are used (Maguire, 1990). These include demonstration of key skills, practice under controlled conditions and audio or video-tape feedback of performance by a tutor in small groups. More complex skills can also be learned but may not be used or maintained without ongoing training and supervision. The most effective training programmes use simulated patients, role play, video play back and feedback from experienced facilitators (Bird, Hall, Maguire, & Heavy, 1993; Silverman, Kurtz, & Draper,

1998; Falloweld, Lipkin, & Hall, 1998). In its 1993 guidelines on undergraduate medical education, the General Medical Council recognised the need for teaching medical students to communicate clearly, sensitively and effectively with patients, relatives and fellow professionals (GMC, 1993). There were differences of opinion amongst participants relating to which model of decision-making should be adopted. Some favoured an informed choice model, whereas others expressed the view that decision-making should be shared. Related to this, there was no clear view as to how much guidance a doctor should give a patient in relation to the most appropriate option. In the informed choice model (Emanuel & Emanuel, 1992), the physician is obliged to provide all available information and the patients values then determine which treatments should be given. The physicians values have no place as he or she is purely a purveyor of technical expertise, thus providing the patient with the knowledge needed to exercise control. The physician must provide accurate, truthful information and consult others when his or her knowledge is lacking. The conception of patient autonomy is patient control over medical decision-making. However, there is concern from some commentators that because control over decision-making resides entirely with the patient, this may lead to increased anxiety and if taken to its extreme may lead to patients feeling that they have been abandoned (Quill & Brody, 1996). Furthermore, the doctor may feel constrained from giving a treatment recommendation for fear of imposing his or her will on the patient and thereby competing for the autonomy which has been given to the patient. Perhaps more realistic and equitable is the shared model (Charles et al., 1997), where ideally there is a two-way exchange of information so that both doctor and patient reveal treatment preferences and both agree on the decision to implement. Whilst this approach necessitates a patient being fully informed of all the available options, the doctor and patient both have a legitimate investment in the treatment decision, therefore both declare treatment preferences and their rationale whilst building a consensus on the appropriate treatment to implement. Lupton (1997) has hi-lighted the indecision that patients feel between wanting to behave in a consumerist manner and their equally strong desire at other times to take on the passive role. As Elwyn et al. (1999) argue, shared decision-making may offer a balance to these opposing roles by actively involving patients in decision-making and by requiring the doctor to use his or her expertise and experience to guide the patient and make decisions if desired. Participants commonly stated that more consultation time would be needed to practice EBPC. It is doubtful that the pressurised nature of NHS hospital clinics and

600

S. Ford et al. / Social Science & Medicine 56 (2003) 589602

general practice surgeries will allow the time needed to discuss all the options fully, ensure patients understand them, and support them in their decision-making (Schartz & Grubb, 1985). It seems likely that a restructuring of appointments systems will need to take place before the time needed for this approach is realised. Studies to-date indicate that more time in the consultation would be worth striving for. For example, Howie, Heaney, and Maxwell (1997) have shown that time spent within consultations seems to be directly related to the quality of care, with more time increasing the ability of patients to understand and cope with their health problems. Beisecker and Beisecker (1990) have also found that the degree to which patients sought information from their doctors was dependent in part on how long the consultation lasted and whether they were encouraged to raise queries. Establishing the nature of the patients problem was mentioned by a relatively small number of participants as an important element. It seems likely that this was seen as an obvious component of the consultation and hence was not specically identied. In order to formulate a research question and obtain the correct evidence-based information, it is essential for the doctor to elicit the patients reason for attendance. Research conducted in the early 1980s reminds us that doctors tend to interrupt patients after their opening statement so that patients fail to disclose signicant facts relating to their problem (Beckman & Frankel, 1984). In one study in 50% of the consultations reviewed, the patient and doctor did not agree on the nature of the main presenting problem (Stareld et al., 1981). Elicitation of the patients problem(s) seems an obvious task, but unless it is done effectively, using appropriate data gathering skills there is a chance that vital information will be missed. Whilst theoretical models provide thought provoking arguments for the on-going debate concerning doctor control versus patient autonomy, little work has been carried out to introduce these approaches into the consultation process. This is not helped by the lack of a coherent strategy for introducing the evidence base into the consultation and conveying it effectively to the patient. Although our respondents stressed the importance of conveying probability and risks when discussing treatment options, there was no mention of the processes involved to achieve this. For example, should the health professional talk in terms of relative risk, absolute risk, numbers needed to treat and so on. In fairness to them, it was not the aim of our study to grapple with these specic issues, but to explore the main components for an EBPC consultation. Formulating the specic processes involved in this approach poses a complex and challenging exercise, but must be achieved if evidence-based patient choice is to be implemented in practice.

Acknowledgements We thank all those who gave their time to participate in the interviews and our colleagues who gave advice throughout the study, in particular Professor Paul Salkovskis and Joyanne MacInnes. This project was funded by the NHS Anglia and Oxfordshire Regional R & D.

References
Ashcroft, J. J., Leinster, S. J., & Slade, P. D. (1986). Mastectomy vs breast conservation: Psychological effects of patient choice of treatment. In M. Watson, & S. Greer (Eds.), Psychological issues in malignant disease (pp. 5571). Oxford: Pergamon Press. Audit Commission (1993). What seems to be the matter? Communication between hospitals and patients. London: HMSO. Ballard-Reisch, D. (1993). Health care providers and consumers making decisions together. In B. Thornton, & G. Kreps (Eds.), Perspectives on health communication (pp. 66 80). Prospect Heights, IL: Waveland. Barry, M. J., Fowler, F. J., Mulley, A. G., Henderson, J. V., & Wennberg, J. E. (1995). Patient reactions to a program designed to facilitate patient participation in treatment decisions for benign prostatic hyperplasia. Medical Care, 33, 771782. Bass, M. J., Buck, C., Turner, L., Dickie, G., Pratt, G., & Robinson, H. C. (1986). The physicians actions and the outcome of illness in family practice. Journal of Family Practice, 23, 4347. Beaver, K., Bogg, J., & Luker, K. A. (1999). Decision-making role preferences and information needs: A comparison of colorectal and breast cancer. Health Expectations, 2, 266276. Beaver, K., Luker, K. A., Owens, R. G., Leinster, S. J., Degner, L. F., & Sloan, J. A. (1996). Treatment decision making in women newly diagnosed with breast cancer. Cancer Nursing, 19(1), 819. Beckman, H. B., & Frankel, R. M. (1984). The effect of physician behavior on the collection of data. Annals of Internal Medicine, 101, 692696. Beisecker, A. E., & Beisecker, T. D. (1990). Patient information-seeking behaviours when communicating with doctors. Medical Care, 28(1), 1928. Bensing, J. (2000). Bridging the gap. The separate worlds of evidence-based medicine and patient-centered medicine. Patient Education and Counseling, 39(1), 1725. Bird, J., Hall, A., Maguire, G. P., & Heavy, A. (1993). Workshops for consultants on the teaching of clinical communication skills. Medical Education, 27, 181185. Braddock, C. H., Edwards, K. A., Hasenberg, N. M., Laidley, T. L., & Levinson, W. (1999). Informed decision making in outpatient practice. Journal of the American Medical Association, 282, 23132320. Brody, D. S. (1980). The patients role in clinical decision making. Annals of Internal Medicine, 93, 718722.

S. Ford et al. / Social Science & Medicine 56 (2003) 589602 Brody, H. (1985). Autonomy revisited: Progress in medical ethics: Discussion paper. Journal of the Royal Society of Medicine, 78, 380387. Buetow, S., & Kenealy, T. (2000). Evidence-based medicine: The need for a new denition. Journal of Evaluation in Clinical Practice, 6, 8592. Charles, C., Gafni, A., & Whelan, T. (1997). Shared decisionmaking in the medical encounter: What does it mean? (Or, it takes at least two to tango). Social Science & Medicine, 44, 681692. Charles, C., Gafni, A., & Whelan, T. (1999). Decision-making in the physician-patient encounter: Revisiting the shared treatment decision-making model. Social Science & Medicine, 49, 651661. Coulter, A., Entwistle, V., & Gilbert, D. (1998). Informing patients: An assessment of the quality of patient information materials. London: Kings Fund. Davidoff, F., Haynes, B., Sackett, D., & Smith, R. (1995). Evidence based medicine. A new journal to help doctors identify the information they need. British Medical Journal, 310, 10851086. Deber, R. B. (1994a). The patient-physician partnership: Changing roles, and the desire for information. Canadian Medical Association Journal, 151, 171176. Deber, R. B. (1994b). The patient-physician partnership: Decision making, problem solving, and the desire to participate. Canadian Medical Association Journal, 151, 423427. Degner, L. F., Kristjanson, L. J., Bowman, D., Sloan, J. A., Carriere, K. C., ONeil, J., Bilodeau, B., Watson, P., & Mueller, B. (1997). Information needs and decisional preferences in women with breast cancer. Journal of the American Medical Association, 277, 14851492. Degner, L. F., & Sloan, J. A. (1992). Decision-making during serious illness: What role do patients really want to play? Journal of Clinical Epidemiology, 45, 941950. Department of Health (2000). The NHS Plan. A plan for investment. A plan for reform. London: Stationery Ofce. Dworkin, G. (1988). The theory and practice of autonomy. New York: Cambridge University Press. Edwards, A., Elwyn, G., & Gwyn, R. (1999). General practice registrar responses to the use of different risk communication tools: Problems and opportunities. British Medical Journal, 319, 749752. Elwyn, G., Edwards, A., & Kinnersley, P. (1999). Shared decision-making in primary care: The neglected second half of the consultation. British Journal of General Practice, 49, 477482. Elwyn, G., Edwards, A., Kinnersley, P., & Grol, R. (2000). Shared decision making and the concept of equipoise: The competences of involving patients in healthcare choices. British Journal of General Practice, 50(460), 892899. Emanuel, E. J., & Emanuel, L. L. (1992). Four models of the physician-patient relationship. Journal of the American Medical Association, 267, 22212226. Ende, J., Kazis, L., Ash, A., & Moskowitz, M. A. (1989). Measuring patients desire for autonomy: Decision-making and information-seeking preferences among medical patients. Journal of General Internal Medicine, 4, 2330. Entwistle, V. A., Sheldon, T. A., Sowden, A., & Watt, I. S. (1998). Evidence-informed patient choice: Practical issues of

601

involving patients in decisions about health care technologies. International Journal of Technology Assessment in Health Care, 14, 212225. Falloweld, L. J., Hall, A., Maguire, G. P., & Baum, M. (1990). Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial. British Medical Journal, 301, 575580. Falloweld, L. J., Hall, A., Maguire, P., Baum, M., & AHern, R. P. (1994). Psychological effects of being offered choice of surgery for breast cancer. British Medical Journal, 309, 448. Falloweld, L., Lipkin, M., & Hall, A. (1998). Teaching senior oncologists communication skills: Results from phase i of a comprehensive longitudinal program in the united kingdom. Journal of Clinical Oncology, 16, 19611968. Ford, S., Schoeld, T., & Hope, T. (2001). Barriers to the evidence-based patient choice (EBPC) consultation. Patient Education & Counseling, in press. General Medical Council (Great Britain) Education Committee (1993). Tomorrows doctors: Recommendations on undergraduate medical education. London: GMC. Green, J. (1998). Grounded theory and the constant comparative method. British Medical Journal, 316, 10601065. Greeneld, S., Kaplan, S. H., Ware, J. E., Yano, E. M., & Frank, H. J. L. (1988). Patients participation in medical care: Effects on blood sugar and quality of life in diabetes. Journal of General Internal Medicine, 3, 448457. Guadagnoli, E., & Ward, P. (1998). Patient participation in decision-making. Social Science & Medicine, 47, 329339. Hope, T. (1996). Evidence based patient choice. London: Kings Fund. Howie, J. G. R., Heaney, D., & Maxwell, M. (1997). Measuring quality in general practice: A pilot study of a needs, process and outcome measure. London: Royal College of General Practitioners. Jacobson, L. D., Edwards, A. G. K., Granier, S. K., & Butler, C. C. (1997). Evidence-based medicine and general practice. British Journal of General Practice, 47, 449452. Janis, I. (1982). Effective interventions in decision counseling: Implications of the ndings from 23 eld experiments. In I. Janis (Ed.), Counseling on personal decisions: Theory and research on short-term helping relationships. New Haven, CT: Yale University Press. Jenkins, V., Falloweld, & Saul, J. (2001). Information needs of patients with cancer: results from a large study in UK cancer centres. British Journal of Cancer, 84(1), 4851. Kinmonth, A. L., Woodcock, A., Grifn, S., Spiegal, N., & Campbell, M. -J. (1998). Randomised controlled trial of patient centred care of diabetes in general practice: Impact on current wellbeing and future disease risk. The diabetes care from diagnosis research team. British Medical Journal, 317(7167), 12021208. Laine, C., & Davidoff, F. (1996). Patient-centred medicine: A professional evolution. Journal of the American Medical Association, 275, 152156. Lupton, D. (1997). Consumerism, reexivity and the medical encounter. Social Science & Medicine, 45, 373381. Maguire, P. (1990). Can communication skills be taught? British Journal of Hospital Medicine, 43(3), 215216. Mayer, J., & Piterman, L. (1999). The attitudes of Australian GPs to evidence-based medicine: A focus group study. Family Practice, 16, 627632.

602

S. Ford et al. / Social Science & Medicine 56 (2003) 589602 practice and teach EBM (2nd ed.). London: Churchill Livingstone. Savage, R., & Armstrong, D. (1990). Effect of a general practitioners consulting style on patients satisfaction: A controlled study. British Medical Journal, 301(6758), 968 970. Schartz, R., & Grubb, A. (1985). Why Britain cant afford informed consent. Hastings Center Report (pp. 1925). Sheppard, S., Charnock, D., & Gann, B. (1999). Helping patients access high quality health information. British Medical Journal, 319, 764766. Silverman, J., Kurtz, S., & Draper, J. (1998). Skills for communicating with patients. Abingdon: Radcliffe Medical Press. Smith, D., Garko, M., Bennett, K., Irwin, H., & Schoeld, T. (1994). Patient preferences for delegation and participation: Cross national support for mutuality. Australian Journal of Communication, 21, 86108. Stareld, B., Wray, C., Hess, K., Gross, R., Birk, P. S., & DLugoff, B. C. (1981). The inuence of patient-practitioner agreement on outcome of care. American Journal of Public Health, 71(2), 127131. Stewart, M. A. (1995). Effective physician-patient communication and health outcomes: A review. Canadian Medical Association Journal, 152(9), 14231433. Strull, W. M., Lo, B., & Charles, G. (1984). Do patients want to participate in medical decision making? Journal of the American Medical Association, 252, 29902994. Towle, A., & Godolphin, W. (1999). Framework for teaching and learning informed shared decision making. British Medical Journal, 319(7212), 766771. Veatch, R. M. (1982). Making health care decisions: the ethical and legal implications of informed consent in the patientpractitioner relationship. Vol. 1. Washington, DC: Government Printing Ofce. Wagner, E. H., Barrett, P., Barry, M. J., Barlow, W., & Fowler, F. J. (1995). The effect of a shared decision making program on rates of surgery for benign prostatic hyperplasia pilot results. Medical Care, 33(8), 765770.

McColl, A., Smith, H., White, P., & Field, J. (1998). General practitioners perceptions of the route to evidence-based medicine: A questionnaire survey. British Medical Journal, 316, 361365. McKinley, J., Cattermole, H., & Oliver, C. W. (1999). The quality of surgical information on the internet. Journal of the Royal College of Surgeons of Edinburgh, 44, 265268. Meredith, C., Symonds, P., Webster, L., Lamont, D., Pyper, E., Gillis, C. R., & Falloweld, L. (1996). Information needs of cancer patients in west Scotland: Cross sectional survey of patients views. British Medical Journal, 313(7056), 724726. Muir Gray, J. A., & de Lusignan S, . (1999). National electronic library for health (NeLH). British Medical Journal, 319, 14761479. NHS Executive (1995). Priorities and planning guidance for the NHS: 1996/97. Leeds: NHS Executive. NHS Executive (1996). Patient partnership: Building a collaborative strategy. Leeds: NHS Executive. Protheroe, J., Fahey, T., Montgomery, A. A., & Peters, T. J. (2000). The impact of patients preferences on the treatment of atrial brillation: Observational study of patient based decision analysis. British Medical Journal, 320, 13801384. Quill, T. E., & Brody, H. (1996). Physician recommendations and patient autonomy: Finding a balance between physician power and patient choice. Annals of Internal Medicine, 122, 766771. Reiser, S. J. (1993). The era of the patient: Using the experience of illness in shaping the missions of health care. Journal of the American Medical Association, 269, 10121017. Roter, D. L. (1983). Physician/patient communication: Transmission of information and patient effects. Maryland State Medical Journal, 32, 260265. Sacchetti, P., Zvara, P., & Plante, M. K. (1999). The internet and patient education resources and their reliability: Focus on a select urologic topic. Urology, 53, 117120. Sackett, D. L., Straus, S., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidence-based medicineFhow to