Shared decision making in consultations when an option grid is introduced. Is the OG an artificial interruption in an otherwise artful consultation? A discourse analysis.

The problem

Decision aids aim to reduce power imbalances and promote patient participation and improved awareness of treatment options. There is evidence that they can reduce health inequalities for patients with lower health literacy levels. However, interrupting established patterns in consulting to introduce tools such as Option Grids can be daunting. Clinicians can be sceptical and nervous of using them, although they gain positive feedback after practice. We look at consultations where an Option Grid is introduced to discuss knee osteoarthritis treatments. We examine practical issues with using the option grid.

The approach

This discourse analysis study was embedded in a trial (the TOGA study) designed to evaluate the impact of introducing Option Grids into consultations conducted by six physiotherapists in an interface clinic for osteoarthritis in Oldham, Greater Manchester. 72 consultations were audio-recorded. 12 consultations in which the Option Grid had been used were randomly selected. These were transcribed following a discourse analysis protocol.Two researchers independently repeatedly viewed the transcripts and listened to the audio-recordings before discussing patterns and examples and developing key issues in the scenarios. Comments were discussed with a third researcher to increase validity. Interviews with patients and clinicians after the consultation were reviewed to establish fidelity for the discussion points emerging from our analysis.

Findings

Clinicians took time learning to adapt the option grid to particular circumstances but showed progressive confidence with this. Clinicians learnt to adapt the grid to exclude certain options, tailoring it to the patient as they became more familiar with using it.A significant issue was how the option grid was introduced into the consultation. In most cases the fluidity of the consultations faltered. Clinicians finished taking a history/examining the patient, and then stumbled over introducing the grid. In general they did not discuss shared decision making as a concept and introduce the option grid as part of this wider discussion. The meta-talk (or orientation) when introducing the grid was brief, and patient involvement was limited.

Consequences

Introducing the Option Grid appeared difficult for clinicians but became more practical with repeated use. Use of the Option Grid to improve patient participation was not optimal. Ways to improve this may be by wider discussion about shared decision making; talking about choices, options and decisions, rather than introducing the option grid as a relatively narrow focus. This suggests direction for clinician training in future.

Credits

• Katie Phillips, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire, USA
• Fiona Wood, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire, USA
• Glyn Elwyn
• Adrian Edwards, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire, USA
• The TOGA Group, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire, USA