A discourse analysis of the nature of shared decision-making in general practice consultations
This study explores the nature of shared decision-making (SDM) in general practice consultations. It has been claimed that patient involvement in their own health and healthcare improves concordance, patient satisfaction and outcomes. Although this approach to treatment decision-making is widely advocated the process of sharing decisions has, to date, been little understood. Cognitivist or intra-psychic assumptions about decision-making have underpinned the traditional methods of investigation into the doctor-patient consultation and as a result interactional dynamics have not taken centre stage. Participants' motivations and emotions have been 'read' as enduring entities rather than as discursive constructions attending to interactional matters. As a consequence most of the work into the medical encounter has tended to be one-sided and addresses only one participant at a time. Thus, one half of the interaction may be neglected. Therefore, only a partial picture of the nature of interaction is provided. In summary therefore, traditional approaches have not considered the medical encounter as a process of joint-production and decision-making as an emergent property of the interaction. In contrast this study adopts a discourse analytic approach that allows for a fine-grained examination of what might be described as the minutiae of the interactional flow and trajectory of consultation. An examination of the content and form of the consultation-as-interaction has been undertaken in order to identify and describe a variety of discursive devices and resources that participants deploy to accomplish particular activities. As a result, the analysis provides an insight into the actual processes of the SDM consultation and how treatment decisions are arrived at. The primary data source was audio-recorded consultations having been initially identified from a questionnaire survey and patient interviews. Three analytic themes that are key aspects of the SDM consultation are examined. These are, the generation of patient involvement using first-person pronouns; the construction of direct, successful and unsuccessful requests from patients; the rhetorical construction of risk and evidence, with attention to the locating of agency. The analytic conclusions illuminate the complexities arising within the medical encounter and highlight problem aspects which impact on the theoretical and philosophical foundations SDM. Notably, SDM does not happen with the ease implied by current models and may work to maintain a biomedical GP as 'expert' approach rather one in which the patient is truly involved in partnership. In short, new information is available on the consultation process. This information has implications for health care practice and communication skills training and existing models of SDM may need to be re-evaluated.