Is 'shared decision-making' feasible in consultations for upper respiratory tract infections? Assessing the influence of antibiotic expectations using discourse analysis

• Published in: Health expectations : an international journal of public participation in health care and health policy 1999-05, Vol.2 (2), p.105-117
• Main Authors: Elwyn, Glyn, Gwyn, Richard, Edwards, Adrian, Grol, Richard
• Format: Article
• Language: English
• Subjects: antibiotic prescribing; Antibiotics; Communication skills; Competence; Decision making; Decision making models; Discourse analysis; Doctor-Patient interactions; Evidence-based medicine; Family physicians; Feasibility; General practice; Group decision making; Illnesses; Information content; Internal medicine; Medical diagnosis; Medicine; Misconceptions; Normality; Original; patient participation; Patients; Prescribing; professional practice; Qualitative analysis; Qualitative research; Recurrence; Respiratory diseases; Respiratory disorders; Respiratory tract; Respiratory tract infection; Respiratory tract infections; shared decision-making; Social sciences; Treatment; Treatment preferences; Urban areas
• ISSN: 1369-6513; 1369-7625
• DOI: 10.1046/j.1369-6513.1999.00045.x

Objectives To examine the discourse of consultations in which conflict occurs between parents and clinicians about the necessity of antibiotics to treat an upper respiratory tract infection. To appraise the feasibility of shared decision‐making in such consultations. Design A qualitative study using discourse analysis techniques. Setting A general practice with 12 500 patients in an urban area of Cardiff, Wales. Participants Two consultations were purposively selected from a number of audiotaped sessions. The consultations took place during normal clinics in which appointments are booked at 7‐minute intervals. The practitioner is known to be interested in involving patients in treatment decisions. Method Discourse analysis was employed to examine the consultation transcripts. This analysis was then compared with the theoretical competencies proposed for ‘shared decision‐making’. Results The consultations exhibit less rational strategies than those suggested by the shared decision‐making model. Strong parental views are expressed (overtly and covertly) which seem derived from prior experiences of similar illnesses and prescribing behaviours. The clinician responds by emphasizing the ‘normality’ of upper respiratory tract infections and their recurrence, accompanied by expressions that antibiotic treatment is ineffective in ‘viral’ illness – the suggested diagnosis. The competencies of ‘shared decision‐making’ are not exhibited. Conclusions The current understanding of shared decision‐making needs to be developed for those situations where there are dis‐agreements due to the strongly held views of the participants. Clinicians have limited strategies in situations where patient treatment preferences are opposed to professional views. Dispelling ‘misconceptions’ by sharing information and negotiating agreed management plans are recommended. But it seems that communication skills, information content and consultation length have to receive attention if such strategies are to be employed successfully.