Welcome to the sixteenth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

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DISCUSSING (OPEN ACCESS THROUGH JULY 31, 2018; CLICK ON TITLE TO ACCESS)

A Qualitative Analysis of Patients’ Perceptions of Shared Decision Making in the Emergency Department: “Let Me Know I Have a Choice”
Elizabeth M. Schoenfeld MD, MS  Sarah L. Goff MD  Gwendolyn Downs DO  Robert J. Wenger DO Peter K. Lindenauer MD, MSc  Kathleen M. Mazor EdD

LISTEN NOW: INTERVIEW WITH LEAD AUTHOR DR. SCHOENFELD

ABSTRACT:

Background and Objectives
Despite increasing attention to the use of shared decision making (SDM) in the emergency department (ED), little is known about ED patients’ perspectives regarding this practice. We sought to explore the use of SDM from the perspectives of ED patients, focusing on what affects patients’ desired level of involvement and what barriers and facilitators patients find most relevant to their experience.

Methods
We conducted semistructured interviews with a purposive sample of ED patients or their proxies at two sites. An interview guide was developed from existing literature and expert consensus and based on a framework underscoring the importance of both knowledge and power. Interviews were recorded, transcribed, and analyzed in an iterative process by a three‐person coding team. Emergent themes were identified, discussed, and organized.

Results
Twenty‐nine patients and proxies participated. The mean age of participants was 56 years (range, 20 to 89 years), and 13 were female. Participants were diverse in regard to race/ethnicity, education, number of previous ED visits, and presence of chronic conditions. All participants wanted some degree of involvement in decision making. Participants who made statements suggesting high self‐efficacy and those who expressed mistrust of the health care system or previous negative experiences wanted a greater degree of involvement. Facilitators to involvement included familiarity with the decision at hand, physicians’ good communication skills, and clearly delineated options. Some participants felt that their own relative lack of knowledge, compared to that of the physicians, made their involvement inappropriate or unwanted. Many participants had no expectation for SDM and although they did want involvement when asked explicitly, they were otherwise likely to defer to physicians without discussion. Many did not recognize opportunities for SDM in their clinical care.

Conclusions
This exploration of ED patients’ perceptions of SDM suggests that most patients want some degree of involvement in medical decision making but more proactive engagement of patients by clinicians is often needed. Further research should examine these issues in a larger and more representative population.

ADDITIONAL READING:

Probst MA, Kanzaria HK, Schoenfeld EM, Menchine MD, Breslin M, Walsh C, et al. Shared Decisionmaking in the Emergency Department: A Guiding Framework for Clinicians. Annals of Emergency Medicine. 2017 Nov;70(5):688–95. 

Schoenfeld EM, Goff SL, Elia TR, Khordipour ER, Poronsky KE, Nault KA, et al. A Qualitative Analysis of Attending Physicians' Use of Shared Decision-Making: Implications for Resident Education. Journal of Graduate Medical Education. 2018 Feb;10(1):43–50.