- Email: [email protected]
The place of persuasion in shared decision making: A contextual approach. A response to Eggly
Social Science & Medicine 69 (2009) 12–13
Contents lists available at ScienceDirect
Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed
The place of persuasion in shared decision making: A contextual approach. A response to Eggly Orit Karnieli-Miller a, *, Zvi Eisikovits b a b
Department of Community Mental Health, & Concentration for Excellence in Patient-Professional Relationship in Health Care, University of Haifa, Mount Carmel, Haifa 31905, Israel School of Social Work, University of Haifa, Israel
a r t i c l e i n f o Article history: Available online 21 May 2009
We thank Susan Eggly for her commentary ‘‘Can Physicians Both Persuade and Partner?’’ (Eggly, 2009) and the other Social Science & Medicine reviewers for providing us with an outstanding learning opportunity arising from the critical debate surrounding our paper. We would like to use this opportunity to reassure Dr. Eggly and the readers that we made every effort to enhance the quality and credibility of the study. We agree that all qualitative data are subjective. In the manuscript, we differentiate between data collected about the encounter itself (real-time encounters) i.e. the dynamics, what was said, to whom, when and how; and the participants’ perceptions of these dynamics. Dr. Eggly herself stated in her commentary that ‘‘researchers who strive to combine objective observations with subjective self-reports in this context generally document clinical interactions through the use of audioor video-recording’’ (Eggly, 2009). This is the exact process used in this study. All observations were audio-taped, and transcribed verbatim. They were then systematically analyzed in a discursive process by each author and subsequently discussed with a qualitative method research group and two additional physicians uninvolved in the study. As opposed to the quantitative term of reliability and validity stated by Dr. Eggly, we used several wellknown qualitative techniques to increase the trustworthiness of the findings, among them multiple triangulation (Denzin, 1970), including investigator triangulation mentioned above; method triangulation – a creative combination of diverse types of data collection (observations and interviews) (Moran-Ellis et al., 2006); and participant triangulation – using different informants’ points of view (Moran-Ellis et al., 2006), in this case, the adolescent patient, the parents and the physician, to hear ‘‘all sides of a story’’ (Forbat, 2003; Henderson & Forbat, 2002; Song, 1998). These interviews, with all participants involved, provided information about the situation from the individuals’ perspectives and provided knowledge that transcends that of the observer (Arksey & Knight, 1999). * Corresponding author. Tel.: þ972 48288643; fax: þ972 774041174. E-mail address: [email protected] (O. Karnieli-Miller). 0277-9536/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2009.04.029
This was enhanced by the use of the ‘‘think aloud’’ technique, in which participants were asked to describe their feelings about specific moments in the encounter. This method expanded our ability to learn about the usually unspoken conscious thoughts (Green & Gilhooly, 1996), by adding information and insights concerning the motives underlying each behavior pattern (Jones & Bugge, 2006). In addition, we provided the reader with as much context as possible about each case, as well as transparency of the process and findings, using verbatim translated quotes to give the reader the opportunity to decide about the authors’ interpretation credibility. Despite this, we still acknowledge that in qualitative research in general, there is no one objective truth, but only a construction of it, and actually a range of constructions (Mason, 2002), reflecting the researchers’ perspectives of the data (see also Jones & Bugge, 2006). In the manuscript, we stated our subjective belief (bias) that shared decision making is the ethical way to practice treatment decisions. The literature review clearly indicated its ethical, legal and logical benefits. Needless to say, a qualitative study should be inductive, and the present study meets this demand. This manuscript is part of a larger study examining interactions which involved breaking bad news. Shared decision making was not a part of our cognitive map as researchers, but rather emerged around the key theme of treatment decisions as discussed between the patient and the doctors. The inductive findings identified several conversational methods applied by physicians. These conversational methods were grounded in the data and were not ‘‘borrowed’’ from any previous literature. For example, we did not use the terminology of shared decision making during the data collection (we did not expect it to be relevant) or in the analysis (we did not use pre-defined themes). It became an issue only following the inductive open coding that identified key themes that reiterated the importance of treatment decisions and the multiple ways they are generated. If we had used a deductive process, we would have analyzed the data while specifically searching for shared decision making practices, rather than inductively finding the motives, decisions and application of persuasion tactics, as we did.
O. Karnieli-Miller, Z. Eisikovits / Social Science & Medicine 69 (2009) 12–13
Eggly concludes that our manuscript condemns the use of persuasive communication, and she quotes different headings from the methods section to illustrate this assertion (Eggly, 2009). We disagree. Let us examine first the terminology and the title headings. Much of the terminology used in the manuscript (e.g. ‘winning compliance’ or the use of the term ‘manipulation’) were insiders’ terms used by the participating physicians to describe their actions and motives. A second type of heading was purely descriptive, reflecting the action taken, e.g. ‘‘emphasizing the ability to control the side effects of treatment.’’ In describing this communicative tactic, we wrote that the use of this tactic emphasizes the physician’s ‘‘responsibility. and increases the level of confidence in him and his suggestions’’ (Karnieli-Miller & Eisikovits, 2009). This statement is not intended to condemn the use of this communication pattern to convince/market the treatment option. It is meant to describe what was applied. A third type of heading included terms that were based on our interpretation of the findings (e.g. ‘‘dramatizing the evil’’). This term is not derogatory, but rather reflective of divergent definitions of the situation arising from different sets of values (Tannenbaum, 1938). Our intent was to identify and describe these types of treatment communication patterns and to see how they relate to shared decision making practices. We do believe that some of them can be applied when sharing a decision, but only following the application of other critical elements of shared decision making (such as providing enough information, creating an environment that allows negotiation). This leads us to wonder about Dr. Eggly’s conclusion that physicians in our study applied shared decision making principles. It seems to us that this conclusion stems from de-contextualization of some of the findings. For example, we clearly stated that ‘‘only partial information was provided about the diagnosis. and most focused on enhancing the chances of accepting the treatment option preferred by the physician; seldom was there a two-way flow of information (e.g. patients’ preferences regarding treatment were not checked); choices were often presented in a way that required immediate decision making, thereby limiting time and opportunity for reflection and deliberation’’ (Karnieli-Miller & Eisikovits, 2009). All these are critical elements of shared decision making, especially during a stressful encounter of receiving bad news. The need for deliberation and reflection are especially critical, as Eggly herself indicated, in that encounters that involve breaking bad news include multiple pieces of information that can be defined as bad news, when one of them can be the treatment (Eggly et al., 2006), as it occurred in some cases presented here. Various critically important papers (e.g., Brown, Butow, Butt, Moore, & Tattersall, 2004) discussing shared decision making practices indicate that providing an alternative or persuading the patient to take your preferred treatment are not independent factors indicating whether a decision has been shared. Rather, several components taken together may lead to this conclusion, such as an explicit statement offering a rationale for sharing the decision; sharing an understanding of the illness (Brown et al., 2004). Only by looking at the context, which includes the dynamics during the entire encounter, the way treatment is presented and the opportunity to negotiate, deliberate and share the decision, can one assess whether the decision was shared or not. Our paper focused on shared decision making and informed shared decision making (Towle & Godolphin, 1999). Informed shared decision making constitutes ‘‘.decisions that are shared by doctor and patient and informed by best evidence, not only about risks and benefits but also patient specific characteristics and values’’ (p. 766). As indicated above, these decisions should be based both on the physicians’ preference for treatment (that is, based on the belief that this is the best medical option – as in this study), but also on the exploration and discussion of patients’
13
preferences. As Dr. Eggly points out, a physician may legitimately prefer one treatment over the other as s/he states this preference (Eggly, 2009); however, the expectation of stating the other available options still stands, as these may be preferred by the patients. Such an approach allows for negotiation aimed at finding the optimal treatment for the specific patient and his/her family. We agree with Dr. Eggly that persuasion should not be considered as inherently unacceptable or unethical behavior. In this paper, we explicitly wrote that these persuasive strategies encouraged some patients and families to trust the physician and believe in the treatment suggested. However, the context of the persuasion, and the absence of additional principles such as providing more information and explaining other alternatives, does play a role. We explore this issue even further in the paper, when we identify several difficulties in ‘fully’ applying these principles, especially during an encounter that involves breaking bad news. These include important contextual considerations related to the difficulties in creating partnership in the treatment choice during the initial stage of a relationship, when they barely know one another (Charles, Gafni, & Whelan, 1999; Whitney et al., 2006); when they are faced with a major knowledge gap; or due to attitudes supporting physicians’ decisions on their behalf (e.g. Thompson, 2007). Our call joins that of others (Whitney, McGuire, & McCullough, 2004) to empower patients and work collaboratively to arrive at a shared decision. Our findings show that there is still a way to go to achieve this goal, and understanding the role of persuasion in practice brings it closer. References Arksey, H., & Knight, P. (1999). Interviewing for social scientists. London: Sage. Brown, R. F., Butow, P. N., Butt, D. G., Moore, A. R., & Tattersall, M. H. N. (2004). Developing ethical strategies to assist oncologists in seeking informed consent to cancer clinical trials. Social Science & Medicine, 58(2), 379–390. 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, 651–661. Denzin, N. K. (1970). The research act in sociology: A theoretical introduction to sociological methods. London: Butterworths. Eggly, S., Penner, L., Albrecht, T. L., Cline, R. J. W., Foster, T., Naughton, M., et al. (2006). Discussing bad news in the outpatient oncology clinic: rethinking current communication guidelines. Journal of Clinical Oncology, 24(4), 716–719. Eggly, S. (2009). Can physicians both persuade and partner? A commentary on Karnieli-Miller and Eisikovits. Social Science & Medicine, 69(1), 9–11. Forbat, L. (2003). Relationship difficulties in dementia care: a discursive analysis of two women’s accounts. Dementia: The International Journal of Social Research and Practice, 2(1), 67–84. Green, C., & Gilhooly, K. (1996). Protocol analysis: practical implementation. In J. T. E. Richardson (Ed.), Handbook of qualitative research methods for psychology and the social sciences (pp. 55–74). Leicester: The British Psychological Society. Henderson, J., & Forbat, L. (2002). Relationship based social policy: personal and policy constructions of care. Critical Social Policy, 22(4), 665–683. Jones, A., & Bugge, C. (2006). Improving understanding and rigour through triangulation: an exemplar based on patient participation in interaction. Journal of Advanced Nursing, 55(5), 612–621. Karnieli-Miller, O., & Eisikovits, Z. (2009). Physician as partner or salesman? Shared decision-making in real-time encounters. Social Science & Medicine, 69(1), 1–8. Moran-Ellis, J., Alexander, V. D., Cronin, A., Fielding, M., Sleney, J., & Thomas, H. (2006). Triangulation and integration: processes, claims and implications. Qualitative Research, 6(1), 45–59. Mason, J. (2002). Qualitative researching. London: Sage Publications. Song, M. (1998). Hearing competing voices. In J. Ribbens, & R. Edwards (Eds.), Feminist dilemmas in qualitative research (pp. 103–118). London: Sage. Tannenbaum, F. (1938). Crime and the community. New York: Columbia University Press. Thompson, A. G. H. (2007). The meaning of patient involvement and participation in health care consultations: a taxonomy. Social Science & Medicine, 64, 1297–1310. Towle, A., & Godolphin, W. (1999). Framework for teaching and learning informed shared decision making. British Medical Journal, 319, 766–769. Whitney, S. N., Ethier, A. M., Fruge´, E., Berg, S., McCullough, L. B., & Hockenberry, M. (2006). Decision-making in pediatric oncology: who should take the lead? The decisional priority in pediatric oncology model. Journal of Clinical Oncology, 24(1), 160–165. Whitney, S. N., McGuire, A. L., & McCullough, L. B. (2004). A typology of shared decision making, informed consent, and simple consent. Annals of Internal Medicine, 140(1), 54–59.
Contents lists available at ScienceDirect
Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed
The place of persuasion in shared decision making: A contextual approach. A response to Eggly Orit Karnieli-Miller a, *, Zvi Eisikovits b a b
Department of Community Mental Health, & Concentration for Excellence in Patient-Professional Relationship in Health Care, University of Haifa, Mount Carmel, Haifa 31905, Israel School of Social Work, University of Haifa, Israel
a r t i c l e i n f o Article history: Available online 21 May 2009
We thank Susan Eggly for her commentary ‘‘Can Physicians Both Persuade and Partner?’’ (Eggly, 2009) and the other Social Science & Medicine reviewers for providing us with an outstanding learning opportunity arising from the critical debate surrounding our paper. We would like to use this opportunity to reassure Dr. Eggly and the readers that we made every effort to enhance the quality and credibility of the study. We agree that all qualitative data are subjective. In the manuscript, we differentiate between data collected about the encounter itself (real-time encounters) i.e. the dynamics, what was said, to whom, when and how; and the participants’ perceptions of these dynamics. Dr. Eggly herself stated in her commentary that ‘‘researchers who strive to combine objective observations with subjective self-reports in this context generally document clinical interactions through the use of audioor video-recording’’ (Eggly, 2009). This is the exact process used in this study. All observations were audio-taped, and transcribed verbatim. They were then systematically analyzed in a discursive process by each author and subsequently discussed with a qualitative method research group and two additional physicians uninvolved in the study. As opposed to the quantitative term of reliability and validity stated by Dr. Eggly, we used several wellknown qualitative techniques to increase the trustworthiness of the findings, among them multiple triangulation (Denzin, 1970), including investigator triangulation mentioned above; method triangulation – a creative combination of diverse types of data collection (observations and interviews) (Moran-Ellis et al., 2006); and participant triangulation – using different informants’ points of view (Moran-Ellis et al., 2006), in this case, the adolescent patient, the parents and the physician, to hear ‘‘all sides of a story’’ (Forbat, 2003; Henderson & Forbat, 2002; Song, 1998). These interviews, with all participants involved, provided information about the situation from the individuals’ perspectives and provided knowledge that transcends that of the observer (Arksey & Knight, 1999). * Corresponding author. Tel.: þ972 48288643; fax: þ972 774041174. E-mail address: [email protected] (O. Karnieli-Miller). 0277-9536/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2009.04.029
This was enhanced by the use of the ‘‘think aloud’’ technique, in which participants were asked to describe their feelings about specific moments in the encounter. This method expanded our ability to learn about the usually unspoken conscious thoughts (Green & Gilhooly, 1996), by adding information and insights concerning the motives underlying each behavior pattern (Jones & Bugge, 2006). In addition, we provided the reader with as much context as possible about each case, as well as transparency of the process and findings, using verbatim translated quotes to give the reader the opportunity to decide about the authors’ interpretation credibility. Despite this, we still acknowledge that in qualitative research in general, there is no one objective truth, but only a construction of it, and actually a range of constructions (Mason, 2002), reflecting the researchers’ perspectives of the data (see also Jones & Bugge, 2006). In the manuscript, we stated our subjective belief (bias) that shared decision making is the ethical way to practice treatment decisions. The literature review clearly indicated its ethical, legal and logical benefits. Needless to say, a qualitative study should be inductive, and the present study meets this demand. This manuscript is part of a larger study examining interactions which involved breaking bad news. Shared decision making was not a part of our cognitive map as researchers, but rather emerged around the key theme of treatment decisions as discussed between the patient and the doctors. The inductive findings identified several conversational methods applied by physicians. These conversational methods were grounded in the data and were not ‘‘borrowed’’ from any previous literature. For example, we did not use the terminology of shared decision making during the data collection (we did not expect it to be relevant) or in the analysis (we did not use pre-defined themes). It became an issue only following the inductive open coding that identified key themes that reiterated the importance of treatment decisions and the multiple ways they are generated. If we had used a deductive process, we would have analyzed the data while specifically searching for shared decision making practices, rather than inductively finding the motives, decisions and application of persuasion tactics, as we did.
O. Karnieli-Miller, Z. Eisikovits / Social Science & Medicine 69 (2009) 12–13
Eggly concludes that our manuscript condemns the use of persuasive communication, and she quotes different headings from the methods section to illustrate this assertion (Eggly, 2009). We disagree. Let us examine first the terminology and the title headings. Much of the terminology used in the manuscript (e.g. ‘winning compliance’ or the use of the term ‘manipulation’) were insiders’ terms used by the participating physicians to describe their actions and motives. A second type of heading was purely descriptive, reflecting the action taken, e.g. ‘‘emphasizing the ability to control the side effects of treatment.’’ In describing this communicative tactic, we wrote that the use of this tactic emphasizes the physician’s ‘‘responsibility. and increases the level of confidence in him and his suggestions’’ (Karnieli-Miller & Eisikovits, 2009). This statement is not intended to condemn the use of this communication pattern to convince/market the treatment option. It is meant to describe what was applied. A third type of heading included terms that were based on our interpretation of the findings (e.g. ‘‘dramatizing the evil’’). This term is not derogatory, but rather reflective of divergent definitions of the situation arising from different sets of values (Tannenbaum, 1938). Our intent was to identify and describe these types of treatment communication patterns and to see how they relate to shared decision making practices. We do believe that some of them can be applied when sharing a decision, but only following the application of other critical elements of shared decision making (such as providing enough information, creating an environment that allows negotiation). This leads us to wonder about Dr. Eggly’s conclusion that physicians in our study applied shared decision making principles. It seems to us that this conclusion stems from de-contextualization of some of the findings. For example, we clearly stated that ‘‘only partial information was provided about the diagnosis. and most focused on enhancing the chances of accepting the treatment option preferred by the physician; seldom was there a two-way flow of information (e.g. patients’ preferences regarding treatment were not checked); choices were often presented in a way that required immediate decision making, thereby limiting time and opportunity for reflection and deliberation’’ (Karnieli-Miller & Eisikovits, 2009). All these are critical elements of shared decision making, especially during a stressful encounter of receiving bad news. The need for deliberation and reflection are especially critical, as Eggly herself indicated, in that encounters that involve breaking bad news include multiple pieces of information that can be defined as bad news, when one of them can be the treatment (Eggly et al., 2006), as it occurred in some cases presented here. Various critically important papers (e.g., Brown, Butow, Butt, Moore, & Tattersall, 2004) discussing shared decision making practices indicate that providing an alternative or persuading the patient to take your preferred treatment are not independent factors indicating whether a decision has been shared. Rather, several components taken together may lead to this conclusion, such as an explicit statement offering a rationale for sharing the decision; sharing an understanding of the illness (Brown et al., 2004). Only by looking at the context, which includes the dynamics during the entire encounter, the way treatment is presented and the opportunity to negotiate, deliberate and share the decision, can one assess whether the decision was shared or not. Our paper focused on shared decision making and informed shared decision making (Towle & Godolphin, 1999). Informed shared decision making constitutes ‘‘.decisions that are shared by doctor and patient and informed by best evidence, not only about risks and benefits but also patient specific characteristics and values’’ (p. 766). As indicated above, these decisions should be based both on the physicians’ preference for treatment (that is, based on the belief that this is the best medical option – as in this study), but also on the exploration and discussion of patients’
13
preferences. As Dr. Eggly points out, a physician may legitimately prefer one treatment over the other as s/he states this preference (Eggly, 2009); however, the expectation of stating the other available options still stands, as these may be preferred by the patients. Such an approach allows for negotiation aimed at finding the optimal treatment for the specific patient and his/her family. We agree with Dr. Eggly that persuasion should not be considered as inherently unacceptable or unethical behavior. In this paper, we explicitly wrote that these persuasive strategies encouraged some patients and families to trust the physician and believe in the treatment suggested. However, the context of the persuasion, and the absence of additional principles such as providing more information and explaining other alternatives, does play a role. We explore this issue even further in the paper, when we identify several difficulties in ‘fully’ applying these principles, especially during an encounter that involves breaking bad news. These include important contextual considerations related to the difficulties in creating partnership in the treatment choice during the initial stage of a relationship, when they barely know one another (Charles, Gafni, & Whelan, 1999; Whitney et al., 2006); when they are faced with a major knowledge gap; or due to attitudes supporting physicians’ decisions on their behalf (e.g. Thompson, 2007). Our call joins that of others (Whitney, McGuire, & McCullough, 2004) to empower patients and work collaboratively to arrive at a shared decision. Our findings show that there is still a way to go to achieve this goal, and understanding the role of persuasion in practice brings it closer. References Arksey, H., & Knight, P. (1999). Interviewing for social scientists. London: Sage. Brown, R. F., Butow, P. N., Butt, D. G., Moore, A. R., & Tattersall, M. H. N. (2004). Developing ethical strategies to assist oncologists in seeking informed consent to cancer clinical trials. Social Science & Medicine, 58(2), 379–390. 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, 651–661. Denzin, N. K. (1970). The research act in sociology: A theoretical introduction to sociological methods. London: Butterworths. Eggly, S., Penner, L., Albrecht, T. L., Cline, R. J. W., Foster, T., Naughton, M., et al. (2006). Discussing bad news in the outpatient oncology clinic: rethinking current communication guidelines. Journal of Clinical Oncology, 24(4), 716–719. Eggly, S. (2009). Can physicians both persuade and partner? A commentary on Karnieli-Miller and Eisikovits. Social Science & Medicine, 69(1), 9–11. Forbat, L. (2003). Relationship difficulties in dementia care: a discursive analysis of two women’s accounts. Dementia: The International Journal of Social Research and Practice, 2(1), 67–84. Green, C., & Gilhooly, K. (1996). Protocol analysis: practical implementation. In J. T. E. Richardson (Ed.), Handbook of qualitative research methods for psychology and the social sciences (pp. 55–74). Leicester: The British Psychological Society. Henderson, J., & Forbat, L. (2002). Relationship based social policy: personal and policy constructions of care. Critical Social Policy, 22(4), 665–683. Jones, A., & Bugge, C. (2006). Improving understanding and rigour through triangulation: an exemplar based on patient participation in interaction. Journal of Advanced Nursing, 55(5), 612–621. Karnieli-Miller, O., & Eisikovits, Z. (2009). Physician as partner or salesman? Shared decision-making in real-time encounters. Social Science & Medicine, 69(1), 1–8. Moran-Ellis, J., Alexander, V. D., Cronin, A., Fielding, M., Sleney, J., & Thomas, H. (2006). Triangulation and integration: processes, claims and implications. Qualitative Research, 6(1), 45–59. Mason, J. (2002). Qualitative researching. London: Sage Publications. Song, M. (1998). Hearing competing voices. In J. Ribbens, & R. Edwards (Eds.), Feminist dilemmas in qualitative research (pp. 103–118). London: Sage. Tannenbaum, F. (1938). Crime and the community. New York: Columbia University Press. Thompson, A. G. H. (2007). The meaning of patient involvement and participation in health care consultations: a taxonomy. Social Science & Medicine, 64, 1297–1310. Towle, A., & Godolphin, W. (1999). Framework for teaching and learning informed shared decision making. British Medical Journal, 319, 766–769. Whitney, S. N., Ethier, A. M., Fruge´, E., Berg, S., McCullough, L. B., & Hockenberry, M. (2006). Decision-making in pediatric oncology: who should take the lead? The decisional priority in pediatric oncology model. Journal of Clinical Oncology, 24(1), 160–165. Whitney, S. N., McGuire, A. L., & McCullough, L. B. (2004). A typology of shared decision making, informed consent, and simple consent. Annals of Internal Medicine, 140(1), 54–59.