The Physician-as-Stakeholder: An Exploratory Qualitative Analysis of Physicians’ Motivations for Using Shared Decision-Making in the Emergency Department

Abstract

Background

Shared decision-making (SDM) is increasingly recognized as an important facet of patient-centered care. Despite growing interest in SDM in the emergency department, little is known about emergency physicians’ (EP) motivations for using SDM. Understanding current patterns of SDM use and EP's rationale for using SDM is essential for the development of interventions to increase use.

Objectives

Recognizing the emergency physician as an important stakeholder in SDM research, we sought to identify and explore factors that may motivate emergency physicians’ engagement in shared decision-making.

Methods

In this qualitative study, informed by the Theory of Planned Behavior and Social Cognitive Theory, we conducted semi-structured interviews with a purposeful sample of EPs. Interviews were recorded and transcribed verbatim. Using a directed qualitative content analysis approach, 3 members of the research team performed open coding of the transcripts in an iterative process, building a provisional code book as coding progressed. Respondent validation was employed to ensure methodological rigor.

Results

Fifteen emergency physicians, ages 31-65, from both academic and community practice settings, were interviewed. Several had not heard of the specific phrase “shared decision-making,” but all understood the concept and felt they used SDM techniques to some degree. Most noted they had often had an agenda when they used SDM, which often motivated them to have the conversation. Agendas described included counteracting an algorithmic or defensive approach to diagnosis and treatment, avoiding harmful tests, or sharing uncertainty. All participants believed patients benefited from SDM in terms of satisfaction, engagement, or education. Nearly all participants identified research outcomes that they felt would encourage their use of SDM (e.g. improvements in patient engagement, mitigation of risk) and many prioritized patient-centered outcomes over systems outcomes such as improved resource utilization. Little consensus was seen, however, regarding the importance of individual outcomes: of eight potential research outcomes participants endorsed, no single outcome was endorsed by even half of the physicians interviewed.

Conclusion

Emergency physicians identified many factors that motivated them to use SDM. This study informs current research on SDM in the ED, particularly regarding the motivations of the physician-as-stakeholder.

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