The role of the medical schools in encouraging the future generation of clinicians to be more open with patients about uncertainties
Dear Editor,
Rightly, Dr Chalmers points out to the necessity for clinicians to
initiate discussion about scientific uncertainties with their patients,
the general public and researchers(1). In a society in which the mindset
is striving for certainty(2), it is necessary to reflect on how this shift
in paradigm might be more likely to occur. When we translated and adapted
in French the clinician’s version of the Decisional Conflict Scale
(DCS)(3) (a scale that assesses how uncertain one is when facing a
difficult decision), participating clinicians clearly indicated to us that
we should rename the scale, the Decisional Comfort Scale(4). When we did
some pilot work regarding attitudes of family medicine practitioners
towards shared decision making, we observed that they were not quite
convinced that sharing information and scientific uncertainty with their
patients was good for the patients. These physicians were afraid that this
would provoke anxiety in patients while they perceived their role was one
of buffering anxiety. Our observations were in line with what other
researchers have reported in this area: physicians are not at ease with
actively engaging patients in making health-related decision(5,6); they
fear this will provoke undue anxiety(7,8) when in fact, they believe that
one important goal they can achieve is to buffer patients’ anxiety(9).
Interestingly, the results of a systematic review about the impact of
providing complex information to patients with decision aids were found
not to be compatible with an increase in patients’ anxiety(10). Previous
work by Gerrity and other researchers have emphasised the contribution of
physicians’ reaction to uncertainty and of physicians’ reluctance to
disclose uncertainty on patient-related outcomes(11,12).
Therefore, we agree with Dr Chalmers that medical schools have an
important role to play in encouraging the future generation of clinicians
to be more open with patients about the limitations of treatment and their
potential harm. The Department of Family Medicine of Laval University has
had as its mission to train family doctors. Among the abilities most
highly valued by our department, that dealing with a decision making
process of the highest possible quality between patient and doctor is a
key concern of all our members, be they clinicians, teachers or
researchers. This decision making process has to be able to integrate the
best scientific evidence, to respect the patient’s values and to take into
account the desired role in the decision-making process. In partnership
with the Canadian Research Chair in Health Care Consumer Decision
Support(13), the department is currently supporting a research project
aimed at introducing shared decision making processes into the context of
family medicine teaching units(14). Up to this date, 6 out of the 8 units
have actively participated in the project. A total of 721 clinical
encounters have been conjointly assessed by 112 participating health care
providers and their patients using the DCS. This reflects a response rate
of our members over 70%. A total of 14 interactive workshops that aimed at
educating physicians about models of shared decision making have been
attended by most of them. We will be analysing our data shortly. However,
we can share with our colleagues that encouraging clinicians to be more
open with patients about the scientific uncertainties associated with
health-related decisions will keep many of us busy and require that we be
tolerant to the uncertain outcome of our endeavours.
Sincerely yours,
France Légaré, MD, MSC, (F)CCMF
Doctoral student
Population Health Program
University of Ottawa
Clinical teacher
Département de médecine familiale
Université Laval
Québec, Québec
Canada
G1K 7P4
email: france.legare@mfa.ulaval.ca
Funding: FL receives a salary funded by the Canadian Institutes of
Health Research (CIHR) Institute of Health Services and Policy Research
(IHSPR). The research project that aims at introducing shared decision
making processes into the context of family medicine teaching units
associated with the Department of Family Medicine of Laval University is
funded by the Canadian Research Chair in Health Care Consumer Decision
Support and the KT ICE research group from the University of Ottawa.
1. Chalmers I. Well informed uncertainties about the effects of
treatments. BMJ 2004;328:475-6.
2. Bricker D, Greenspon D. Searching for Certainty: Inside the New
Canadian Mindset. Toronto: Doubleday Canada; 2001.
3. Dolan JG. A method for evaluating health care providers' decision
making: the Provider Decision Process Assessment Instrument. Med Decis
Making 1999;19:38-41.
4. Légaré F, Graham I, O'Connor A, Dolan J, Bélanger-Ducharme F.
Prise de décision partagée : traduction et validation d'une échelle de
confort décisionnel du médecin. Pédagogie médicale 2003;4:216-22.
5. Elwyn G, Edwards A, Gwyn R, Grol R. Towards a feasible model for
shared decision making: focus group study with general practice
registrars. BMJ 1999;319:753-6.
6. Godolphin W, Towle A, McKendry R. Challenges in family practice
related to informed and shared decision-making: a survey of preceptors of
medical students. CMAJ 2001;165:434-5.
7. Murray E, Davis H, Tai SS, Coulter A, Gray A, Haines A. Randomised
controlled trial of an interactive multimedia decision aid on benign
prostatic hypertrophy in primary care. BMJ 2001;323:493-6.
8. Tudiver F, Guibert R, Haggerty J, Ciampi A, Medved W, Brown JB,
Herbert C, Katz A, Ritvo P, Grant B, Goel V, Smith P, O'Beirne M, Williams
JI, Moliner P. What influences family physicians' cancer screening
decisions when practice guidelines are unclear or conflicting? J Fam Pract
2002;51:760.
9. West AF, West RR. Clinical decision-making: coping with
uncertainty. Postgrad Med J 2002;78:319-21.
10. Bekker H, Légaré F, Stacey D, O'Connor A, Lemyre L. Is anxiety a
suitable measure of decision aid effectiveness?: a systematic review.
Patient Educ Couns 2003;50:255-62.
11. Gerrity MS, DeVellis RF, Earp JA. Physicians' reactions to
uncertainty in patient care. A new measure and new insights. Med Care
1990;28:724-36.
12. Allison JJ, Kiefe CI, Cook EF, Gerrity MS, Orav EJ, Centor R. The
association of physician attitudes about uncertainty and risk taking with
resource use in a Medicare HMO. Med Decis Making 1998;18:320-9.
13. Ottawa Health Research Institute. Canadian Research Chair in
Health Care Consumer Decision Support. www.ohri.ca/decisionaid (accessed
27 Feb.2004).
Competing interests:
FL is responsible for supervising the research project that aims at introducing shared decision making processes into the context of family medicine teaching units associated with the Department of Family Medicine of Laval University.
Competing interests:
No competing interests
01 March 2004
France Légaré
clinical teacher
Département de médecine familiale, Université Laval, Québec, Québec, Canada, G1L 3L5
Rapid Response:
The role of the medical schools in encouraging the future generation of clinicians to be more open with patients about uncertainties
Dear Editor,
Rightly, Dr Chalmers points out to the necessity for clinicians to
initiate discussion about scientific uncertainties with their patients,
the general public and researchers(1). In a society in which the mindset
is striving for certainty(2), it is necessary to reflect on how this shift
in paradigm might be more likely to occur. When we translated and adapted
in French the clinician’s version of the Decisional Conflict Scale
(DCS)(3) (a scale that assesses how uncertain one is when facing a
difficult decision), participating clinicians clearly indicated to us that
we should rename the scale, the Decisional Comfort Scale(4). When we did
some pilot work regarding attitudes of family medicine practitioners
towards shared decision making, we observed that they were not quite
convinced that sharing information and scientific uncertainty with their
patients was good for the patients. These physicians were afraid that this
would provoke anxiety in patients while they perceived their role was one
of buffering anxiety. Our observations were in line with what other
researchers have reported in this area: physicians are not at ease with
actively engaging patients in making health-related decision(5,6); they
fear this will provoke undue anxiety(7,8) when in fact, they believe that
one important goal they can achieve is to buffer patients’ anxiety(9).
Interestingly, the results of a systematic review about the impact of
providing complex information to patients with decision aids were found
not to be compatible with an increase in patients’ anxiety(10). Previous
work by Gerrity and other researchers have emphasised the contribution of
physicians’ reaction to uncertainty and of physicians’ reluctance to
disclose uncertainty on patient-related outcomes(11,12).
Therefore, we agree with Dr Chalmers that medical schools have an
important role to play in encouraging the future generation of clinicians
to be more open with patients about the limitations of treatment and their
potential harm. The Department of Family Medicine of Laval University has
had as its mission to train family doctors. Among the abilities most
highly valued by our department, that dealing with a decision making
process of the highest possible quality between patient and doctor is a
key concern of all our members, be they clinicians, teachers or
researchers. This decision making process has to be able to integrate the
best scientific evidence, to respect the patient’s values and to take into
account the desired role in the decision-making process. In partnership
with the Canadian Research Chair in Health Care Consumer Decision
Support(13), the department is currently supporting a research project
aimed at introducing shared decision making processes into the context of
family medicine teaching units(14). Up to this date, 6 out of the 8 units
have actively participated in the project. A total of 721 clinical
encounters have been conjointly assessed by 112 participating health care
providers and their patients using the DCS. This reflects a response rate
of our members over 70%. A total of 14 interactive workshops that aimed at
educating physicians about models of shared decision making have been
attended by most of them. We will be analysing our data shortly. However,
we can share with our colleagues that encouraging clinicians to be more
open with patients about the scientific uncertainties associated with
health-related decisions will keep many of us busy and require that we be
tolerant to the uncertain outcome of our endeavours.
Sincerely yours,
France Légaré, MD, MSC, (F)CCMF
Doctoral student
Population Health Program
University of Ottawa
Clinical teacher
Département de médecine familiale
Université Laval
Québec, Québec
Canada
G1K 7P4
email: france.legare@mfa.ulaval.ca
Funding: FL receives a salary funded by the Canadian Institutes of
Health Research (CIHR) Institute of Health Services and Policy Research
(IHSPR). The research project that aims at introducing shared decision
making processes into the context of family medicine teaching units
associated with the Department of Family Medicine of Laval University is
funded by the Canadian Research Chair in Health Care Consumer Decision
Support and the KT ICE research group from the University of Ottawa.
1. Chalmers I. Well informed uncertainties about the effects of
treatments. BMJ 2004;328:475-6.
2. Bricker D, Greenspon D. Searching for Certainty: Inside the New
Canadian Mindset. Toronto: Doubleday Canada; 2001.
3. Dolan JG. A method for evaluating health care providers' decision
making: the Provider Decision Process Assessment Instrument. Med Decis
Making 1999;19:38-41.
4. Légaré F, Graham I, O'Connor A, Dolan J, Bélanger-Ducharme F.
Prise de décision partagée : traduction et validation d'une échelle de
confort décisionnel du médecin. Pédagogie médicale 2003;4:216-22.
5. Elwyn G, Edwards A, Gwyn R, Grol R. Towards a feasible model for
shared decision making: focus group study with general practice
registrars. BMJ 1999;319:753-6.
6. Godolphin W, Towle A, McKendry R. Challenges in family practice
related to informed and shared decision-making: a survey of preceptors of
medical students. CMAJ 2001;165:434-5.
7. Murray E, Davis H, Tai SS, Coulter A, Gray A, Haines A. Randomised
controlled trial of an interactive multimedia decision aid on benign
prostatic hypertrophy in primary care. BMJ 2001;323:493-6.
8. Tudiver F, Guibert R, Haggerty J, Ciampi A, Medved W, Brown JB,
Herbert C, Katz A, Ritvo P, Grant B, Goel V, Smith P, O'Beirne M, Williams
JI, Moliner P. What influences family physicians' cancer screening
decisions when practice guidelines are unclear or conflicting? J Fam Pract
2002;51:760.
9. West AF, West RR. Clinical decision-making: coping with
uncertainty. Postgrad Med J 2002;78:319-21.
10. Bekker H, Légaré F, Stacey D, O'Connor A, Lemyre L. Is anxiety a
suitable measure of decision aid effectiveness?: a systematic review.
Patient Educ Couns 2003;50:255-62.
11. Gerrity MS, DeVellis RF, Earp JA. Physicians' reactions to
uncertainty in patient care. A new measure and new insights. Med Care
1990;28:724-36.
12. Allison JJ, Kiefe CI, Cook EF, Gerrity MS, Orav EJ, Centor R. The
association of physician attitudes about uncertainty and risk taking with
resource use in a Medicare HMO. Med Decis Making 1998;18:320-9.
13. Ottawa Health Research Institute. Canadian Research Chair in
Health Care Consumer Decision Support. www.ohri.ca/decisionaid (accessed
27 Feb.2004).
14. Département de médecine familiale de l'université Laval. Projet
Perspective Confort Décisionnel.
www.fmed.ulaval.ca/mfa/Recherche/Confort_decisionnel/PCD.htm (accessed 27
Feb.2004).
Competing interests:
FL is responsible for supervising the research project that aims at introducing shared decision making processes into the context of family medicine teaching units associated with the Department of Family Medicine of Laval University.
Competing interests: No competing interests