Patients have a strong desire to engage in shared decisionmaking with their physicians but this wish is often stymied by “authoritarian” doctors or patients' fears of being perceived as “difficult,” according to a study by the Palo Alto (Calif.) Medical Foundation Research Institute published by Health Affairs
In December 2009, the researchers interviewed 48 people broken into six focus groups. The participants were selected at random from the electronic health records of five primary-care physicians in the San Francisco area, and most were white, well-educated and more than 50 years old, and 19 reported annual incomes of $100,000 or more.
The researchers wrote that they uncovered four main themes from the participants' responses: Patients feel compelled to conform to “socially sanctioned roles” when speaking with their doctor; physicians can be authoritarian; patients work to fill information gaps; and patients feel the need to bring social support to consultations with their physician.
Participants said they feared that questioning their doctors' recommendations would appear to be a challenge to their expertise and authority and ultimately lead to resentment which would have consequences down the line. “Is it going to come out in some other way that's going to lower the quality of my treatment?” one patient asked, while another, according to the study, said: “Will he do what I want but … resent it and therefore not quite be as good?”
Another patient recalled apologizing to a physician when they disagreed over the need for surgery. “I hope I didn't upset you by saying I don't want surgery,” the report quoted the patient as saying. “It isn't that I don't trust you or like you. … I hope you're not mad at me.”
Others noted that their doctor was “authoritarian, rather than authoritative” and perpetuated a negative physician stereotype.
Still others reported covertly going online to learn about treatment options because they didn't want to “rock the boat” by asking their doctor questions. Some said they sought out online medical information because the short visit with their doctor didn't allow time to ask questions.
“Time pressure and the lack of patient-centered information are important structural challenges to shared decisionmaking,” the authors concluded. “However, our findings suggest there are also deeper attitudinal barriers that impede the widespread implementation of shared decisionmaking in routine practice. If patients retain these perceptions and physicians do not work to alter them, it is unlikely that patients will feel safe to participate in shared decisionmaking.”