Ingredients for a Successful Evidence-based a Qualitative Study. Barriers to the Evidence-based Patient Choice (EBPC) vs EBM. Paper Study. Evidence based medicine interest

7/30/2019 Ingredients for a Successful Evidence-based a Qualitative Study. Barriers to the Evidence-based Patient Choice (EB

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Social Science & Medicine 56 (2003) 589602

What are the ingredients for a successful evidence-based

patient choice consultation?: A qualitative study

Sarah Ford*, Theo Schofield, Tony Hope

The Ethox Centre, Institute of Health Sciences, University of Oxford, Old Road, Headington, Oxford OX3 7LF, UK

Abstract

The evidence-based patient choice (EBPC) approach is one of a number of newly emerging templates for medicalencounters that advocate evidence-informed choice and shared decision-making. These models emphasise respect for

patient preferences for involvement in health care decisions and advocate the sharing of good quality evidence-based

information. In the medical consultation EBPC involves providing patients with evidence-based information in a way

that facilitates their ability to make choices or decisions about their health care. Whereas the key principles of shared

decision-making have been conceptualised, so far, no qualitative investigations have been undertaken to establish the

key components of an EBPC consultation. Therefore, a series of semi-structured interviews were carried out with key

informants to identify the elements and skills required for a successful EBPC consultation to occur. The interviews were

conducted with purposively selected UK general practitioners (n 11), hospital doctors (n 10), practice nurses

(n 5), academics (n 11) and lay people (n 8). Qualitative analysis of participants responses was conducted using

the constant comparative method. Six main themes emerged from the data, these were research evidence/medical

information, the doctorpatient relationship, patient perspectives, decision-making processes, time issues and

establishing the patients problem. All respondents placed importance on doctors and patients being well informedand appraised of the latest available medical evidence. There was a general view that evidence-based information

regarding diagnosis and treatment options should be shared with patients during a consultation. However, there were

no suggestions as to how this might be achieved in practice. Participants opinions relating to which model of decision-

making should be adopted ranged from favouring an informed choice model, to the view that decision-making should

be shared equally. Similarly, there was no clear view on how much guidance a doctor should offer a patient during

decision-making concerning the most appropriate treatment option for that patient. r 2002 Elsevier Science Ltd. All

rights reserved.

Keywords: Evidence-based medicine; Patient-centred care; Shared decision-making

Introduction

The term evidence-based patient choice (EBPC)

was first described by Hope (1996) as the merging

together of two important modern movements in

western health care, namely evidence-based medicine

and patient-centred care. This approach is one of several

newly emerging models of the medical encounter which

advocate evidence informed patient choice (Entwistle,

Sheldon, Sowden, & Watt, 1998; Towle & Godolphin,1999) and shared decision-making (Braddock, Edwards,

Hasenberg, Laidley, & Levinson, 1999; Charles, Gafni,

& Whelan, 1999; Elwyn, Edwards, Kinnersley, & Grol,

2000). EBPC is not limited to what has been termed the

neglected second half of the consultation (Elwyn,

Edwards, & Kinnersley, 1999), like most other ap-

proaches it encompasses the whole consultation of

which an important component is patient involvement

in decision-making.

Evidenced-based medicine (EBM) requires the use of

current best evidence to make decisions about the care

of individual patients (Sackett, Straus, Richardson,

*Corresponding author. Tel.: +44-1865-227049; fax: +44-

1865-226938.

E-mail address:[email protected] (S. Ford).

0277-9536/03/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved.

PII: S 0 2 7 7 - 9 5 3 6 ( 0 2 ) 0 0 0 5 6 - 4


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Rosenberg, & Haynes, 2000). Clinical interventions are

recommended on the strength of evidence for their

effectiveness derived mostly from randomised-controlled

trials and systematic reviews. Five basic tenets of EBM

have been identified:

1. clinical decisions should be based on the bestavailable scientific evidence,

2. the clinical problem determines the evidence to be

sought,

3. identifying the best evidence involves epidemiological

and biostatistical ways of thinking,

4. conclusions based on the available evidence are

useful only if put into action for individual patients

or for population health care decisions,

5. performance should be constantly evaluated (David-

off, Haynes, Sackett, & Smith, 1995).

However, in this biomedical approach the individualqualities, needs and preferences of patients have tended

to be neglected as relevant factors in the decision-

making process (Bensing, 2000). Whilst, EBM addresses

the biomedical perspective of diagnosis, mostly from a

doctor-centred paradigm (Jacobson, Edwards, Granier,

& Butler, 1997), doctors also need evidence that is

derived from a patient-centred paradigm that takes into

account the personal and contextual elements of

decision-making in practice. Patient-centred medicine,

is derived from a humanistic, biopsychosocial perspec-

tive and combines ethical values on the ideal doctor,

with psychotherapeutic theories on the facilitation of

patients disclosure of concerns and negotiation theories

on decision-making (Bensing, 2000). This model of care

places a strong emphasis on patient participation in

clinical decision-making by taking into account the

patients needs and preferences. Therefore, in order for

cognitively competent patients to have the power to

make evidence-based choices, as well as being evidence-

based, the medical consultation must be patient-

centred. Providing patients with evidence-based knowl-

edge should enhance their power and aid the develop-

ment of an increasingly effective patient-centred health

care system (Hope, 1996). However, there is a need to

ensure that evidence-based information is conveyed topatients in a way that will increase their understanding

and enable them to make informed choices about their

treatment and management. In the medical consultation,

evidence-based patient choice requires providing pa-

tients with good quality information to facilitate their

ability to make choices or decisions about their health

care. The original theory combines evidence-based

medicine with patient-centred care, so that information

that is of value and personal importance to patients

when making choices (e.g. process of delivery of care) is

considered in parallel with scientific evidence-based

information. However, the term evidence-based is

increasingly becoming outdated as consensus grows that

EBM should acknowledge multiple dimensions of

evidence including practical evidence based on indivi-

duals interpretation of experience (Buetow & Kenealy,

2000). Therefore, evidence-based patient choice must

embrace a broader definition of EBM that includes

evidence produced outside science.

The origins of patient choice

The concept of patient choice originates from

the doctrine of informed consent. In English and US

law a competent person has a legal right to refuse

treatment (even life saving). Valid consent is achieved

only if the individual concerned has been given the

relevant information. Over the last 20 years, medical

ethicists have stressed the importance of the principle of

patient autonomy (Veatch, 1982; Brody, 1985; Dworkin,

1988; Quill & Brody, 1996). This emphasises thatpatients should be in a position to choose whether to

accept an intervention or not as part of their general

right to determine their own lives (Hope, 1996). A

central ethical principle behind evidence-based patient

choice is that the information is being given in order

to enhance choice. Patient choice goes beyond consent

and involves the patient in the decision-making

process. However, the move towards increasing patient

involvement is not driven simply by a theoretical

concern for respect for patient autonomy. Rather, it is

a recognition of the fact that individuals differ both in

what they value and in their propensity to take risks

(Hope, 1996).

Trends in Western health care

Models of shared decision-making and EBPC reflect a

growing trend in health care towards patient empower-

ment and greater patient choice (Department of Health,

2000). This has been fostered by the increasing patient

access to information about treatments and the con-

sumerist trends in modern society (Ballard-Reisch, 1993;

Elwyn et al., 1999). Over the last 20 years or so there has

been a call for more patient choice and personal control

in medical care (Reiser, 1993). Current National HealthService (NHS) initiatives advocate active partnerships

between health professionals and patients (NHS Execu-

tive, 1996) and the improvement of information to help

patients choose between options (NHS Executive, 1995).

Nowadays, most theorists acknowledge that unilateral

decision-making by doctors is unacceptable (except in

certain situations, for example, when a patient is

comatose or in urgent need of life-saving action). The

old paternalistic models of doctorpatient relations have

been rejected by policy makers, and medical academics

in favour of more equitable and collaborative relation-

ships characterised by informed choice. There is a

S. Ford et al. / Social Science & Medicine 56 (2003) 589602590


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growing consensus that sharing decisions is desirable on

humanistic grounds alone (Guadagnoli & Ward, 1998).

Benefits of involving patients

There is also empirical evidence that giving patients

information and involving them in decisions about theirhealth care can result in beneficial psychological and

physical outcomes. For example, enhanced patient

satisfaction Roter (1983), adherence to treatment plans

(Janis, 1982), greater confidence in health care recom-

mendations (Brody, 1980), psychological adjustment to

illness (Fallowfield, Hall, Maguire, & Baum, 1990) and

symptom resolution (Bass et al., 1986). It has also been

found that if patients are actively involved in making

decisions about their care, physiological outcomes such

as diabetic control can be improved (Greenfield,

Kaplan, Ware, Yano, & Frank, 1988). Further evidence

suggests that allowing patients to choose their medicaltreatment can enhance psychological well-being (Ash-

croft, Leinster, & Slade, 1986; Fallowfield et al., 1990,

1994).

In her comprehensive review of health outcomes,

Stewart (1995) concluded that four key dimensions of

communication were related to positive patient out-

comes (emotional health, symptom resolution, function

and physiological health):

* the provision of clear information,* questions from the patient,* willingness to share (discuss) decisions,

* agreement between patient and doctor about theproblem and the plan.

There is also evidence that giving patients information

about the choices open to them can sometimes lead to

fewer prescriptions for specific drugs such as warfarin

(Protheroe, Fahey, Montgomery, & Peters, 2000) and

less demand for some surgical treatments as in the case

of benign prostatic hyperplasia (Barry, Fowler, Mulley,

Henderson, & Wennberg, 1995).

However, there are other studies that show that

although patients prefer patient-centred care, it does not

necessarily enhance physiological outcome. For example

Kinmonth, Woodcock, Griffin, Spiegal, & Campbell(1998) carried out an intervention study to assess the

effect of additional training of practice nurses and GPs

(for abbreviation see Fig. 1) in patient-centred care on

outcomes of patients with newly diagnosed type 2

diabetes. In this study patients in the intervention group

reported better communication with doctors, greater

treatment satisfaction and wellbeing than the compar-

ison group. However, their body mass index was

significantly higher as were triglyceride concentrations.

There is a clear need for more robust studies to

investigate the effects of patient involvement in different

disease groups on a variety of health care outcomes,

including those of a psychological, physiological and

financial nature.

Patient preferences for evidence-based information

Little is known about patients preferences for

evidence-based information during consultations. Thelimited work in this area suggests that for some

conditions, the majority of patients value being given

information about the effectiveness of treatment and

care options (Wagner, Barrett, Barry, Barlow, & Fowler

1995). Inevitably patient preferences are increasingly

being influenced by the consumerist trends in modern

society which, in turn, have fostered better access to

medical information. Developments in Britain such as

local consumer health information services (Sheppard,

Charnock, & Gann, 1999) have improved awareness of,

and access to, evidence-based consumer health informa-

tion. More recently, innovations such as the recentlylaunched National Electronic Library for Health

(NeLH) (Muir Gray & de Lusignan, 1999), now provide

health professionals and patients with easy access to the

most up-to-date evidence of the effectiveness of health-

care interventions. Not surprisingly, patients are becom-

ing increasingly better informed about health care issues

and expect to be given comprehensive information

concerning their diagnosis, prognosis and treatment

options (Jenkins et al., 2001).

Patient involvement in health care

Despite the current trends that advocate greater

patient involvement in health care, whether patients

actually want this is yet to be conclusively demonstrated.

For example, Savage and Armstrong (1990) conducted a

study involving 359 randomly selected patients consult-

ing with one general practitioner to compare the effect

of directing and sharing styles of consultation on patient

satisfaction. The authors found that patients in the

directive group with self-limiting problems or chronic

conditions and those receiving a prescription, reported

significantly higher levels of satisfaction on several

outcome measures. These included: satisfaction with

the GPs perceived understanding of their problem andthe explanation they received.

The results of a study investigating Australian, UK

and US preferences for participation in medical deci-

sion-making suggested that mutuality was the preferred

method of decision-making for participants in all 3

countries (Smith, Garko, Bennett, Irwin, & Schofield,

1994). The authors found that if the question was asked,

Do patients prefer to decide for themselves or delegate

decisions to their doctors? participants chose to

delegate, but if respondents were asked if they preferred

joint decision-making, delegating or deciding they

preferred joint decisions.

S. Ford et al. / Social Science & Medicine 56 (2003) 589602 591


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Most of the empirical research evaluating patient

preferences for participation has been conducted in

North America using high stake scenarios, for

example, decisions concerning treatment for cancer.

Therefore, it is not known whether these findings can be

applied to other patient populations and different

medical contexts, such as patients in general practice.Much of the research is based on surveys using different

assessment measures which makes comparisons difficult

(Deber, 1994a, b; Guadagnoli & Ward, 1998). Studies

conducted using hypothetical questions or contrived

scenarios may not truly reflect patients preferences

during a real clinical interview.

The desire to be involved (or not) in decision-making

may depend on the type and severity of a patients

condition. For example, Beaver et al. (1996) surveyed

150 women recently diagnosed with breast cancer using

a role-preference card-sort (Degner & Sloan, 1992)

which consisted of five cards with a written statementand cartoon depicting increasing levels of patient

involvement. The women were asked to choose their

preferred decision-making role from all possible pairings

of the five cards (ten in total). Results showed that 20%

wanted an active role in deciding their treatment, 28%

preferred a joint decision, and just over half (52%)

wanted their surgeon to decide for them. In contrast a

control group of patients with benign breast disease

wanted to share responsibility for decision-making with

the surgeon. The cancer patients were assessed at an

early stage and had no definite knowledge about their

type of cancer, prognosis or treatment. Therefore, this

lack of information may have contributed to their

reluctance to be more involved in the decision-making

process. In an extension of the above study (Beaver,

Bogg, & Luker, 1999) a comparison of the decision-

making preferences and information needs of colorectal

(n 48) versus breast cancer patients (n 150) was

conducted. Once again a decisional role preference card

sort was used and an information needs questionnaire. It

was found that the majority (78%) of the colorectal

patients preferred to play a passive role in decision-

making, in contrast to 52% of the breast cancer patients.

Of note is the fact that both groups had similar

information needs relating to cure, spread of diseaseand treatment options.

The majority of patients desire for information is

stronger than their desire to be involved in

decision-making (Ende, Kazis, Ash, & Moskowitz,

1989; Strull, Lo, & Charles, 1984; Degner et al., 1997;

Beaver et al., 1999). Furthermore, many patients

would like to receive more information than they

currently do from health care professionals (Audit

Commission, 1993; Meredith et al., 1996). Whether

they wish to be involved in decision-making or not,

patients increasingly expect to be told their diagnosis

and details concerning pathophysiology, treatment

options and prognosis (Laine & Davidoff, 1996;

Meredith et al., 1996).

The purpose of this qualitative study was to identify

the elements and skills required for a successful EBPC

consultation to occur. We stress that we were testing

reactions to a theoretical concept rather than to the

actual existence of the EBPC consultation. The keyprinciples of shared decision-making have already been

conceptualised (Charles et al., 1997; Towle & God-

olphin, 1999). However, no qualitative investigations

have yet been undertaken to establish the key compo-

nents of an EBPC consultation. Therefore, a series of

semi-structured interviews were carried out with key

informants in an attempt to establish these criteria.

Methods and sample

Purposeful sampling was used to recruit participants

who were anticipated to be good informants, i.e., those

likely to have an interest in patient involvement in

decision-making, evidence-based medicine and patient-

centred care. Those invited to take part included UK

general practitioners, hospital doctors, academics, lay

people and nurse practitioners. The GPs and hospital

doctors were medical student tutors affiliated to the UK

Oxford medical communication skills teaching pro-

gramme. Academics were established commentators on

patient involvement in health care. Lay people were

recruited through the Oxfordshire Community Health

Council and had keen interests in issues connected withpatient empowerment. Nurse practitioners were selected

from the surgeries of participating GPs.

All potential participants received a letter which

included basic information about the concept of EBPC

and which invited them to take part in semi-structured

interviews. The explanation of EBPC was presented as

follows:-

In the medical consultation, EBPC means providing

patients with evidence-based information to enable

them to make choices or decisions about their health

care. By combining evidence-based medicine withpatient-centred care, information that is of value and

personal importance to patients is considered in

parallel with scientific evidence-based information as

part of the decision-making process. We would like

your views on the elements and skills needed for

EBPC to take place in the medical consultation.

Those who were willing to take part received a pre-

interview prompt sheet one week before being inter-

viewed. This was to enable them to familiarise them-

selves with the concept of evidence-based patient choice

and make notes on the implications of this approach.



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Eleven GPs (3 of whom were women) agreed to take

part and 10 hospital consultants (4 of whom were

women). Participating academics (4 of whom were part-

time GPs) numbered 11 (7 of whom were women). Eight

lay people agreed to be interviewed (1 of whom was a

male) and 5 nurse practitioners all of whom were

women. In total, the responses of 45 interviewees wereincluded in the qualitative analysis, 26 of whom were

women.

The semi-structured interviews, which were audio-

taped, took place at respondents place of work except

for the lay people, most of whom were interviewed in

their own homes. At the start of each interview the

researcher explored respondents personal understand-

ing of the concept of EBPC. Interviewees were then

asked their opinion on the key components (including

skills) needed for a successful EBPC medical consulta-

tion to occur in practice.

Analysis and coding

The interviews were analysed using the constant

comparison method, a qualitative technique which

involves the systematic sifting and comparison of items

of recorded data to reveal and establish the mutual

relationships and internal structure of categories (Green,

1998). Responses were transcribed and divided into

simpler text units that were entered into a database for

ease of coding. Units of text (at least one complete

thought) referring to similar issues were separated fromdissimilar units and systematically grouped together by

one coder. Each grouping represented a provisional

theme. When all the text units had been coded into the

emergent categories these were tested by being re-

applied by an independent coder. The level of agreement

between the coders for these preliminary codes was

88%. A series of discussions were held and reorganisa-

tion of some of the data took place, before the final

codes were agreed.

Results

Overall, participants had a clear understanding of the

theoretical principles behind evidence-based patient

choice, but perhaps unsurprisingly, were less clear about

the specific processes that might be involved to achieve it

during a medical consultation. Furthermore, GPs and

hospital doctors in particular were rather sceptical about

the successful application of this model in practice. This

scepticism was reinforced by the expression of several

types of barriers to the implementation of this approach

(reported elsewhere, Ford, Schofield, & Hope, 2001).

This general finding is exemplified by the selection of

responses concerning the meaning of EBPC shown in

Fig. 1.

Fig. 2 shows the 6 main themes that emerged from the

data. These are presented below in order of importance,

according to the numbers of respondents and responses

within each one. The categories drawn from each theme

are outlined in Table 1. Due to the exploratory nature ofthis study there are considerable overlaps between some

of the categories and these are emphasised.

Research evidence/medical information

All respondents placed importance on doctors being

well informed and appraised of the latest available

medical evidence. It was also considered desirable for

doctors to have fast and easy access to reliable sources of

evidence, e.g. an NHS desk-top computer link to the

latest research evidence. Related to this, a need wasidentified for doctors to be trained in computerised data

retrieval and to attend training courses on how to

practice evidence-based medicine. Critical appraisal

skills were considered necessary for doctors to enable

them to find the correct evidence, interpret it,

appraise its limitations and apply it appropriately.

It was important for patients to have access to good

sources of evidence, e.g. a reliable internet source.

There was a feeling particularly from academics and lay

people that the quality of written patient information

and internet health sites was generally poor and required

some form of quality control. Good quality evidence for

use by doctors was defined in terms of needing to be

reliable, up-to-date, accurate and comprehen-

sible. This evidence was considered to stem mostly

from randomised clinical trials and evidence-based

guidelines. Other sources of evidence such as patient

experience of care and illness were also acknowledged,

particularly by lay people and academics.

There was a general view that evidence-based

information regarding diagnosis and treatment options

must be shared with patients during a consultation.

Patients should expect to be informed/educated about

the nature of their illnesses/problems and be directed by

the doctor to other sources of information relevant tothe diagnosis. Treatment options were considered best

given in accordance with the strength of the evidence

and choices clearly identified including the option of no

treatment. Fundamental was a description of the

processes, risks/side effects, benefits, possible outcomes

and chances of success for each option. The importance

of honesty was emphasised mostly by academics and lay

people in the context of options, some of which might

not be available on the NHS, and the description of

risks and side effects associated with each treatment

alternative. The sharing of information by doctors

included giving patients graphical representations of



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the evidence, which could aid comprehension, and

providing written evidence-based information about

treatment alternatives. Three academics, 1 GP and 1

hospital doctor suggested that decision aids and/or

written information should be available to help patients

decide which option would be best for them.

Thirty five respondents mentioned ability to convey

complex information as being an essential skill for the

EBPC consultation. There was a strong belief that a

doctor should have the flexibility to adjust the amount

and type of information according to a patients level of

need and understanding. One GP stated that it was

important not to overload the patient with informa-

tion and another insisted that facts and figures should

not dominate the consultation process.

The final category derived from this theme involves

just under half of the total number of respondents. It

concerns fitting or tailoring the evidence to the patient in

question. This was perceived not just in medical terms,

but also involved taking into account the views,

"Well I think it's a fairly utopian concept {yeah} but how actual how pragmatic and realistic it is um I'm probably less sure of {hmm}. I think probably thinking about it, whilst it's an ideal and I think we shouldalways try and achieve ideals and aim high {hmm}. The trouble is that I think the single biggest restraint on itis time and pressure {yeah} and I think its the type of thing which in an ideal circumstance whereby you hadvery long consultations with patients and very small numbers of patients to sort of look after and devotemuch more time to them and their queries then it's something that can be achieved {hmm}; but, the umbut there's a problem at the coal face, of the you know of the NHS in trying to get that done {yeah}."[GP 5]

"Um well given that they have a choice there must be at least two ways of approaching managementum and I guess what we do in the simplest form is say we can either do nothing or we can give you thistreatment , if we do nothing we know from experience this is what will happen {hmn} . If we give you thistreatment we think it will make it better or we know it will make it better and in it's simplest form it's based onthe clinician's interpretation of the available evidence in very simple forms and impressions {ahuh} butand I think that's how it works currently {yes}. There's obviously enormous potential for elaborating that{hmn}, but I have I'm sure some patients would welcome that, but I have to say a lot of patients

particularly in my field when we've tried that just switch off, don't listen, don't want to know and if we go into itin any detail become uncertain um and nervous and full of doubts ."[HD 4]

"Well I think two things, one is the evidence um .. and the other is patient choice, I think that um evidence should be available, I mean first of all as far as is possible clinical decisions should be based onevidence .. um .. and that means that the evidence has to be available both to the doctor and to the patientand sometimes to the patients carers as well - there may be other people involved and there may be morethan one clinician involved um but ideally decisions should be informed by the evidence, I don't thinkthey're necessarily driven by the evidence {ahuh} because the evidence is usually incomplete {ahuh} so theyshould be informed by it {yes}." [AC 1]

"For me it means giving the patient the opportunity to discuss choices of treatment {yup} and then being ableto make an informed decision giving the patient information about treatment and medication which has ascientific track record. This means assessing criteria for different types of treatment whether it's based on asurgical option or a drug based option {ahuh}, and this would mean that for any patient who has any sort of

problem um I think if it has been tried and tested and it has worked for other people {hmm} that's alsonice to know. I can think of examples like arthritis and other sorts of conditions where there are lots of sortsof options, lots of sorts of drugs and even possibly surgery for when it's really bad {yeah}, but I think again a

patient sit ting there would like to have some information about well what's happened in the past - hassomebody tried this {yes} and has it worked, would it work if I had an operation and things like thathaving some kind of proof as to whether something works or not."[LP 3]

"It means trying to present to patients what the evidence is for their problem and listening to their concernsand giving them time to discuss all the options, but at the end of the day it is down to the patient to make thatdecision {yes}. Um for example, I work a lot with students and one of the things is the new introduction ofa new emergency contraception {hmm}, you know and that has huge costing implications {yes}, but youneed to discuss with them the benefits of it, the research that has been shown and advising them in thatrespect {yeah}."[PN 4]

Key: GP = General practitioner, HD = Hospital Doctor, AC = Academic, LP = Lay Person, PN = PracticeNurse

Fig. 1. What does evidence-based patient choice mean to you? (interviewer) (Note: the interviewers speech appears in curly

brackets).



7/14

preferences and personal circumstances of the individual

patient. For example:

You need to apply the evidence to the patient as a

person not just a disease. [HD11]

A doctor needs to apply the evidence according to the

patient as an individual. [AC3]

Doctorpatient relationship

The general characteristics of the doctorpatient

relationship concerned issues, which ideally should be

present in any doctorpatient encounter such as trust,

respect, honesty and partnership building. These issues

were mentioned by the majority of respondents in each

group, exemplified by the following statements:

There should be openness and trust between a doctor

and a patient. [NP5]

The patient should be treated as an individual and an

equal partner. [GP5]

The relationship between a doctor and a patient

should be built up on mutual trust. [LP3]

As with the general characteristics of the doctor

patient relationship, it was felt by respondents that

doctors should have effective communication and

relationship building skills whatever the type of con-

sultation. Therefore, the skills stated are not specifically

those necessary for an EBPC consultation, but could

apply to most doctorpatient encounters. These are

displayed in Table 2, Section 1.

The most frequently mentioned skill was the ability to

listen. Listening to patients was seen as a basic skill to

enable assessment of the language that patients use in

order to pitch information level and to encourage

discussion by listening to patients views without

interruption. Lay people in particular felt that doctors

had a tendency to interrupt and talk over patients. Two

respondents felt that listening was also desirable for

patients:

patients can help doctors by listening and asking

questions when they do not understand. [LP5]

you need to have a sensible patient who listens and

retains information. [HD11]

Patients perspective

Forty two respondents made at least one comment

which related to issues concerning the patients perspec-

tive. Responses related mostly to exploring patients

individual qualities and circumstances. Gaining an

understanding of the patients perspective during a

consultation involved exploration and considera-

tion of expectations, assumptions, anxieties,

concerns, beliefs and values. This was linked to

elicitation of the patients agenda and establishing

patient ideas and level of knowledge concerning the

illness and possible courses of action. Several lay

Responses from 45interviewees

Patients'

Perspectives

Research Evidence/Medical Information

Time Issues

Doctor-Patient

Relationship

Decision MakingProcess

Establishing nature ofthe problem

Fig. 2. Main themes from analysis of elements of a successful EBPC consultation.



8/14

people emphasised the importance of the acknowl-edgement by doctors that patients bring certain personal

qualities to the consultation. For example:

Doctors should acknowledge that patients bring

knowledge to the consultationFthey have life

experiences. [LP1]

The doctor needs to understand that patients have

hopes and fears which often become acute when

illness is an issue. [LE5]

Allied to patient perspectives were preferences for

information and involvement in decision-making. There

were strong views that the doctor must ascertain howmuch and at what level a patient wants to receive

information concerning the medical problem and treat-

ment options. Related to this, it was felt that patients

should have the choice not to be presented with

evidence and should only be given the information

they want and not given details they dont want.

Similarly, ascertaining how much involvement patients

would like in the final decision-making process was

seen as desirable to enable involvement for those that

want it. It was frequently stated by hospital doctors

and GPs that the preferences of patients who wanted

little or no involvement in decision-making should be

Table 1

Main themes and associated categories

Theme Category

Research evidence/medical

information

Access to & knowledge of the evidenceFdoctor needs fast and easy access to the evidence.

Doctor must be well informed of the latest research data; patients also need access to the

latest medical evidence e.g. reliable internet site.QualityFthe evidence must be of good quality (i.e. up-to-date, accurate; reliable;

comprehensible) for doctors and patients.

Appraisal and InterpretationFdoctor must be able to critically appraise evidence in order to

interpret and apply it correctly.

Sharing the evidenceFeducating patient about the condition; guiding him/her to other

sources of information relevant to the diagnosis. Description of the evidence for different

treatment options including implications of no treatment, risks and benefits.

Information-giving skillsFability to: convey/translate complex Information re: evidence/

options; tailor information to patients needs; convey non-directive information, etc.

Fitting the evidence to the patientFdoctor must tailor the evidence/options to the patient in

question taking into account his/her views, values, preferences and personal circumstances.

Doctorpatient relationship General characteristicsFequal partnership, mutual respect, honesty, openness and trust

between both parties; maintenance of privacy and confidentiality, etc.

Interpersonal skills of doctorF

listening, negotiation, cue recognition (verbal and non), useof open and reflective questions, eye contact, ability to put patients at ease, empathy and

appropriate reassurance, non-directive style, etc.

Personal attributes required by doctorFattitude conducive to practising this type of

approach, energy, motivation, confidence, approachability, sensitivity, etc.

Practical issues/settingFenvironment conducive to uninhibited communication; continuity

of care (seeing the same doctor), etc.

Patients perspectives Exploration and consideration of patients perspectivesFexpectations, prior beliefs, anxieties

and concerns, etc.

Patient preferences for information and involvementFspecifically information concerning

medical condition/treatment options and level of involvement desired in decision-making

process

Decision-making process Model of decision-makingFinformed choice, shared decision, etc.

Pre-decision deliberationF

allowing patient time to consider and discuss the options;deferring decision if necessary, etc.

Decision aids/written informationFthese should be available to help patient decide which

option

Level of doctor guidance versus patient autonomy

Post-decision tasksFtime may be needed to reflect on why and how the decision was made;

follow-up arranged if necessary, etc.

Time issues Time needed to seek out evidence

Time needed to discuss options with patients

Establishing nature of problem Obtaining full story from patient

Enabling Patients to tell their own stories



9/14

respected; whereas academics and lay people tended to

emphasise respect for a patients final choice of

treatment.

Decision-making process

Responses concerning the decision-making process

were divided into 4 categories relating to: model of

decision-making, pre-decision deliberations, level of

doctor guidance versus patient autonomy and post-

decision tasks. Thirty five respondents made at least 1

comment for this theme. A range of descriptors was used

to describe the ideal model for deciding the appropriate

treatment for a patient. For example:

The patient must be given the chance to make an

informed choice if he or she wants to. [AC9]

A treatment decision should be negotiated between

doctor and patient. [AC2]

A joint management plan should be worked towards.

[GP12]

If possible decision-making should be shared. [GP8]

Ideally, there should be a partnership approach to

decision-making. [LE1]

There should be a shared discussion of alternatives

resulting in a decisions as to the best option for the

patient. [LE7]

Patients should be encouraged to be part of decision-

making if desired. [PN3]

Commonly mentioned terms were negotiation,

shared and joint. There was overall agreement that

patients should be given the opportunity to be involved

in the final decision-making process if that was what

they desired.

Pre-decision deliberations included allowing patientstime to take in and consider the information; and

providing an opportunity to discuss the choices.

There was general agreement that doctors should help

patients reflect on and assess the impact of

alternative decisions with regard to their individual

circumstances, values and lifestyle. Several aca-

demics felt that patients should be able to defer a

decision and attend for another appointment if neces-

sary.

Responses relating to level of doctor guidance versus

patient autonomy were concerned with how much input

a doctor should have (compared to the patient) after the

options had been discussed, but before a decision hadbeen made.

Responses ranged from: y the doctor should steer

the patient in the direction of the most appropriate

option [HD9] toy need to allow the patient the level

of freedom they need in order to decide on a course

of action [GP12].

It was noticeable that hospital doctors tended to

frown upon providing all the options and then expecting

patients to decide which one was best for them. The

majority felt that doctors should advise patients on the

best course of action for them. On the other hand, laypeople tended to state that doctors should give an

opinion as to which treatment would be the most

appropriate, but the patient should have the right to

reject this. There were two academics who raised the

issue of scientific equipoise, i.e. when there is more than

one equally effective treatment option. One felt that

equipoise should be declared in order to legitimise

patient involvement in decision-making and the other

felt it was important for a doctor to state if patient

choice was arising from a position of scientific equipoise.

Post-decision tasks involved giving patients time to

reflect on why and how the decision was made and

Table 2

EBPC consultation skills

(1) General Communication and relationship building skills

Use of open and reflective questioning techniques

Use of good eye contact

Letting the patient set the pace

Listening skillsPicking up on patients emotional cues and non-verbal clues

Summarising

Clarifying skills

Orienting the patient

Putting patients at ease

Conducting the consultation without clock watching or rushing

the patient

Building up a good rapport

Use of appropriate reassurance

(2) Skills required for evidence-based shared decision-making

Ability to communicate complex information using non-

technical language;Tailoring the amount and pace of information to the patients

needs/preferences;

Drawing diagrams to aid patient comprehension;

Checking patient understanding

Ability to weigh up medical evidence about treatment options

whilst considering the values of the patient;

Conveyance of objective, non-directive information regarding

possible options;

Explanation of probability and risk for each option;

Facilitative skills to encourage patient involvement;

Evaluation of internet information that patients might bring

with them;

Creation of an environment whereby patients feel able to ask

questionsNegotiation skills



10/14

eliciting their understanding of the rationale behind the

decision. It was viewed as being important to arrange a

follow-up visit to check on patients progress and

reconsider the decision if necessary. This was commonly

referred to as an opportunity for more in-put on both

sides.

It was stated by over two thirds of respondents thatdoctors require certain abilities and skills in order to

achieve an evidence-based shared decision (Table 2,

Section 2). Some of these skills overlap with the

information-giving skills previously cited under the

research evidence theme.

Time issues

Overwhelmingly, it was considered important to have

enough time to practice the EBPC approach. In

particular, plenty of time is needed during the consulta-tion to find and discuss the evidence. It was also felt

that a doctor should be willing to see a patient on more

than one occasion to discuss the evidence and options.

One GP said: ideally consultation length should not be

an issue as patients need time to talk and ask questions

about options. Another lay expert believed that

patients could spend a little time preparing for the

consultation beforehand.

Establishing nature of the problem

This theme was the smallest in terms of the number of

contributing respondents. This may be because it was

taken for granted that the primary purpose of the doctor

during any consultation is to ascertain the patients

reason for attending. At least 1 member of each response

group is represented. GPs responses predominate

followed by those of hospital doctors. A common

response concerned obtaining the full story from the

patient in conjunction with checking family history,

background and social circumstances. Lay people

felt it important to let patients describe the problem in

their own words. One hospital doctor emphasised

eliciting psychosocial in addition to medical detailsand information about the patient as an individual.

There was a clear view that the current problem must be

clearly formulated.

Discussion

The analysis of 45 semi-structured interviews brought

to light 6 main themes relating to the essential

ingredients for an EBPC consultation (see Fig. 2). Some

categories were difficult to delineate and as a result there

is some overlap between some of the themes. For

example, recurrent responses running through several

themes were the importance of eliciting the patients

perspective and good communication skills for the

health professional. The elicitation of the patients

values is a precursor of the decision-making process

and is necessary before applying evidence. The patients

perspective is also salient when attempting to establishthe nature of the problem. Similarly, sharing evidence-

based information is a prerequisite for shared decision-

making, which in turn requires the health professional to

have the ability to convey complex medical information.

Therefore, our 6 identified themes are far from concrete

and very much open to further interpretation. Further-

more, participants tended to compartmentalise their

responses so that these related either to the patient-

centred elements of EBPC or the evidence-based

medicine components, but they struggled to join the

two parts of the model together in any depth. Conse-

quently, much of the framework that emerged is inkeeping with a patient-centred model of the consultation

and evidence-based medicine rather than specifically

EBPC. This is an indication that respondents found it

difficult to consider or had no clear idea of how EBPC

could work in reality. Undoubtedly, this reflects the

problematic nature of defining this type of theoretical

approach in practice and this should be borne in mind

when considering the results.

An important theme in terms of number of responses

was research evidence/medical information. This

concerned doctors and patients having the skills to

access and gain knowledge of good quality evidence.

Information giving skills were needed by doctors to

share the evidence with patients and educate them about

their condition. Fitting the evidence to the patient was

also an important component whereby the patients

preferences and personal circumstances are taken into

account in addition to medical criteria. However, recent

research indicates that many doctors are not in touch

with the evidence-base. For example, in a recent a survey

of 302 English GPs (McColl, Smith, White, & Field,

1998) there was a reluctance to acquire the necessary

critical appraisal skills needed in order to track down,

assess and apply evidence to patients. Similarly, Mayer

& Piterman (1999) found that out of the 27 GPS theysurveyed, none expressed a need for critical appraisal

skills. In McColl and colleagues survey (1998), only

20% of GPs had access to Medline or other biblio-

graphic databases and 17% had access to the world wide

web.

Doctors are not the only individuals who need access

to good quality medical evidence. Patients also need

good quality health information to enable them to

become more involved in their medical care. However,

recent studies of patient information materials and

internet health information have found that few sources

meet patients information needs in terms of presenting



11/14

information about the range of relevant treatment

options, and providing a non-biased, evidence-based

view of the effectiveness of each treatment (Coulter,

Entwistle, & Gilbert, 1998; Sacchetti, Zvara, & Plante,

1999; McKinley, Cattermole, & Oliver, 1999).

Communication skills were viewed as particularly

important in relation to sharing the evidenceF

specifi-cally the ability to interpret complex information for

patients. The information sharing stage of a consulta-

tion if it contains probabilistic data is termed risk

communication (Elwyn et al., 1999). The development

of risk communication tools for a course on shared

decision-making has revealed some of the difficulties in

portraying the risks and benefits of commonly encoun-

tered problems (Edwards, Elwyn, & Gwyn, 1999).

Improved ways of communicating risk to patients and

the acquisition of communication skills conducive to

evidence-based patient choice are needed to take this

approach forward.Exploring patient preferences for information and

involvement in decision-making are common stages in

models of shared decision-making (Charles et al. (1997);

Entwistle et al. (1998); Towle & Godolphin, 1999;

Braddock et al., 1999). For some patients the right not

to receive information is an important part of their care

and should be respected (Laine & Davidoff, 1996).

Elwyn, Edwards, and Kinnersley (1999) argue that it

is illogical to ask about a patients preferred role in

decision-making until they have information concerning

the possible harms and benefits of the choices they face.

Only when they are armed with this information will

they be in a position to decide what is best for them. The

majority of patients have a desire for more information

about their illness and treatment options, but only a

small number appear to express a preference to

participate in treatment decisions. More research is

needed to investigate the reasons behind these findings.

The doctorpatient relationship was viewed as an

important element of the EBPC consultation. General

characteristics included mutual respect, honesty and

trust between both parties. Interpersonal skills were key

to the maintenance of a good relationship between

doctor and patient. These included listening, recognising

verbal and non-verbal cues, putting patients at ease,empathy and appropriate reassurance. Basic interview-

ing skills can be learned at undergraduate and post-

graduate level, providing effective methods are used

(Maguire, 1990). These include demonstration of key

skills, practice under controlled conditions and audio or

video-tape feedback of performance by a tutor in small

groups. More complex skills can also be learned but may

not be used or maintained without ongoing training and

supervision. The most effective training programmes use

simulated patients, role play, video play back and

feedback from experienced facilitators (Bird, Hall,

Maguire, & Heavy, 1993; Silverman, Kurtz, & Draper,

1998; Fallowfield, Lipkin, & Hall, 1998). In its 1993

guidelines on undergraduate medical education, the

General Medical Council recognised the need for

teaching medical students to communicate clearly,

sensitively and effectively with patients, relatives and

fellow professionals (GMC, 1993).

There were differences of opinion amongst partici-pants relating to which model of decision-making should

be adopted. Some favoured an informed choice model,

whereas others expressed the view that decision-making

should be shared. Related to this, there was no clear

view as to how much guidance a doctor should give a

patient in relation to the most appropriate option. In

the informed choice model (Emanuel & Emanuel, 1992),

the physician is obliged to provide all available

information and the patients values then determine

which treatments should be given. The physicians

values have no place as he or she is purely a purveyor

of technical expertise, thus providing the patient withthe knowledge needed to exercise control. The physician

must provide accurate, truthful information and consult

others when his or her knowledge is lacking. The

conception of patient autonomy is patient control over

medical decision-making.

However, there is concern from some commentators

that because control over decision-making resides

entirely with the patient, this may lead to increased

anxiety and if taken to its extreme may lead to patients

feeling that they have been abandoned (Quill & Brody,

1996). Furthermore, the doctor may feel constrained

from giving a treatment recommendation for fear of

imposing his or her will on the patient and thereby

competing for the autonomy which has been given to the

patient. Perhaps more realistic and equitable is the

shared model (Charles et al., 1997), where ideally

there is a two-way exchange of information so that both

doctor and patient reveal treatment preferences and

both agree on the decision to implement. Whilst this

approach necessitates a patient being fully informed of

all the available options, the doctor and patient both

have a legitimate investment in the treatment decision,

therefore both declare treatment preferences and their

rationale whilst building a consensus on the appropriate

treatment to implement. Lupton (1997) has hi-lightedthe indecision that patients feel between wanting to

behave in a consumerist manner and their equally

strong desire at other times to take on the passive

role.

As Elwyn et al. (1999) argue, shared decision-making

may offer a balance to these opposing roles by actively

involving patients in decision-making and by requiring

the doctor to use his or her expertise and experience to

guide the patient and make decisions if desired.

Participants commonly stated that more consultation

time would be needed to practice EBPC. It is doubtful

that the pressurised nature of NHS hospital clinics and



12/14

general practice surgeries will allow the time needed to

discuss all the options fully, ensure patients understand

them, and support them in their decision-making

(Schartz & Grubb, 1985). It seems likely that a

restructuring of appointments systems will need to take

place before the time needed for this approach is

realised. Studies to-date indicate that more time in theconsultation would be worth striving for. For example,

Howie, Heaney, and Maxwell (1997) have shown that

time spent within consultations seems to be directly

related to the quality of care, with more time increasing

the ability of patients to understand and cope with their

health problems. Beisecker and Beisecker (1990) have

also found that the degree to which patients sought

information from their doctors was dependent in part on

how long the consultation lasted and whether they were

encouraged to raise queries.

Establishing the nature of the patients problem was

mentioned by a relatively small number of participantsas an important element. It seems likely that this was

seen as an obvious component of the consultation and

hence was not specifically identified. In order to

formulate a research question and obtain the correct

evidence-based information, it is essential for the doctor

to elicit the patients reason for attendance. Research

conducted in the early 1980s reminds us that doctors

tend to interrupt patients after their opening statement

so that patients fail to disclose significant facts relating

to their problem (Beckman & Frankel, 1984). In one

study in 50% of the consultations reviewed, the patient

and doctor did not agree on the nature of the main

presenting problem (Starfield et al., 1981). Elicitation of

the patients problem(s) seems an obvious task, but

unless it is done effectively, using appropriate data

gathering skills there is a chance that vital information

will be missed.

Whilst theoretical models provide thought provoking

arguments for the on-going debate concerning doctor

control versus patient autonomy, little work has been

carried out to introduce these approaches into the

consultation process. This is not helped by the lack of a

coherent strategy for introducing the evidence base into

the consultation and conveying it effectively to the

patient. Although our respondents stressed the impor-tance of conveying probability and risks when discussing

treatment options, there was no mention of the

processes involved to achieve this. For example, should

the health professional talk in terms of relative risk,

absolute risk, numbers needed to treat and so on. In

fairness to them, it was not the aim of our study to

grapple with these specific issues, but to explore the

main components for an EBPC consultation. Formulat-

ing the specific processes involved in this approach poses

a complex and challenging exercise, but must be

achieved if evidence-based patient choice is to be

implemented in practice.

Acknowledgements

We thank all those who gave their time to participate

in the interviews and our colleagues who gave advice

throughout the study, in particular Professor Paul

Salkovskis and Joyanne MacInnes. This project

was funded by the NHS Anglia and OxfordshireRegional R & D.

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