Rapid Responses to:

GENERAL PRACTICE: Glyn Elwyn, Adrian Edwards, Richard Gwyn, and Richard Grol Towards a feasible model for shared decision making: focus group study with general practice registrars BMJ 1999; 319: 753-756 [Abstract] [Full text]

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Rapid Responses published:

Shared decisions or perceived incompetence?

Helen Johnson   (23 September 1999)

sharing without delegating

Richard Birch   (28 September 1999)

Dire Distress Demands Direct Decision

L Reinecke   (25 January 2000)

Shared decisions or perceived incompetence? 23 September 1999
Helen Johnson, SHO A&E Ninewells, Dundee Send response to journal: Re: Shared decisions or perceived incompetence?	I have recently completed vocational training, having spent 18 months in general practice. During that time I have had a lot of teaching about consultation models, and been encouraged to share decision making with patients. In fact, sharing management options is one of the criteria looked for in the video assessment module for MRCGP. In practice, most registrars I spoke to found a similar problem to me; while a principal may be appreciated by patients for sharing decision making with them, this is not necessarily the case with GP registrars. Patients are well aware of the fact that registrars are still learning (to most of them we are still "trainees") and so attempts to share decisions are seen as a reflection of the registrar's lack of knowledge, thus undermining the doctor-patient relationship, rather than enhancing it, which was the original intention.
sharing without delegating 28 September 1999
Richard Birch, GP Registrar Abergavenny Send response to journal: Re: sharing without delegating	As a registrar who was involved in this study I feel qualified to comment on the response by Helen Johnson entitled "Shared decisions or perceived incompetence?" I agree that the process of negotiation can be disturbing to the patient. I had been asking patients their views on treatment before, using language such as "what do you think we should do?" However, after the focus group discussions my approach changed to "I have a few ideas, but would be interested to hear of any feelings you have" I have found that the latter is less likely to evoke the "I don't know your the Doctor!" response and can be seen to be more sharing without delegating. One of the authors was a linguist and it was interesting to explore the language usage in such negotiations. The one aspect that was not reflected in the final publication of the study, was the educational value and change of attitudes that I had following the session.
Dire Distress Demands Direct Decision 25 January 2000
L Reinecke, radiation oncologistr Rand Clinic, Johannesburg, South Africa Send response to journal: Re: Dire Distress Demands Direct Decision	The Editor In your issue on patients participating in decision making the issue which is not adequately covered is that of the immediate decision which must be made by any practitioner who find themselves in a situation where that patient is in dire distress. (1) I will give an example from practice to illustrate the fact that a patient is often not able to appreciate the importance of direct action; even though now practicing as a radiation oncologist. A 65 year old patient (the husband of my receptionist) came to hang pictures on my new consulting room wall. I noticed that he was cyanosed and asked after his health. He said that he was having some chest "discomfort" but that he had an appointment with the cardiac clinic scheduled for a week later. I insisted on sending him to a cardiolgist immediately. He had an angiogram demonstrating 99% obstruction of the anterior descending branch of his left coronary artery. An angioplasty was done and his life was undoubtedly saved. Reference: 1.Elwyn G, Edwards A et.al., BMJ 1999:319:753-756 Editorial note The patient has given his informed signed consent to publication.