Characteristics of Physicians with Participatory Decision-Making Styles

Patients who ask questions, elicit treatment options, express opinions, and state preferences about treatment during office visits with physicians have measurably better health outcomes than patients who do not [1-5]. Patients who feel that they have participated in decision making are more likely to follow through on those decisions than those who do not [6]. This type of involvement has particular relevance for chronic disease care, in which most of the treatment plan must be carried out by patients. To achieve maximum treatment effectiveness, physicians must persuade patients with chronic diseases to commit to and follow through on treatment recommendations. Physicians who routinely involve patients with chronic diseases in treatment decisions (presenting options, discussing the pros and cons of those options, eliciting patient preferences, and reaching mutually agreed-on treatment plans) can be said to have a shared or participatory decision-making style. Such physicians may have greater success in securing patient cooperationand therefore may have better patient health outcomesthan physicians with more controlling decision-making styles. Although research has emphasized greater patient involvement in treatment decisions, less attention has been paid to the physician as an agent for obtaining this result. In studies of patients with hypertension [1], noninsulin-dependent diabetes mellitus [2, 5], peptic ulcer disease [3], and rheumatoid arthritis [7], patients whose physicians were less controlling (or more participatory) during office visits had better functional status and lower follow-up glycosylated hemoglobin levels, blood pressure, and arthritis severity than patients of less participatory physicians. These studies suggest that physicians vary widely in how much they facilitate patients' active participation in treatment decisions (what we have termed a participatory decision-making style). Our study was part of the Medical Outcomes Study, an exploration of differences in the organization of health care delivery and physician reimbursement mechanisms and specialty, and their effect on patients' health outcomes. We examined personal and practice characteristics of physicians likely to influence variations in participatory decision-making style, defined as the propensity to offer patients choices among treatment options and to give them a sense of control and responsibility for care. We relate physicians' background and training, sociodemographic characteristics, practice volume, and satisfaction with professional autonomy to the patient-reported measure of physicians' participatory decision-making styles, after adjusting for patient and practice characteristics. Methods Study Design The study design and sampling strategies of the Medical Outcomes Study have been described [8, 9]. Data for this study derive from a cross-sectional sample of patients obtained from the offices of physicians participating in the Medical Outcomes Study during a 9-day study enrollment period in 1986. Physician and Patient Samples Physicians 31 to 55 years of age who were board eligible or board certified in general internal medicine, family practice, cardiology, or endocrinology were included. The resulting sample of 337 physicians was restricted to the 300 who completed a clinician background questionnaire. These physicians comprised 28 cardiologists (9.3%), 20 endocrinologists (6.7%), 79 family physicians (26.3%), and 173 general internists (57.7%). They were primarily young (mean age SD, 39.2 6.3 years), white (83.7%) men (78.5%). One hundred fifty-five (51.7%) physicians practiced in solo or single-specialty group practices; 52 (17.3%), in multispecialty groups; and 93 (31.0%), in health maintenance organizations. Of 22 463 adult patients of physicians participating in the Medical Outcomes Study, a random half were asked about participatory decision-making style on their screening questionnaire [10]. The patient sample for this analysis was further restricted to only patients (n = 7730) of the 300 physicians who completed the clinician background questionnaire. The average age of patients included in this study was 46.5 17.7 years (range, 18 to 106 years); 20.2% were 65 years of age or older. The patients had completed 13.7 3.0 years of education; most (61.3%) were women, and 21.7% were nonwhite. More than half (53%) had one or more major chronic conditions [8]. Data Collection Data for this study were taken from the Medical Outcomes Study patient and physician screening visit questionnaires and the clinician background questionnaire [10]. The three questions measuring participatory decision-making style were included on the patient screening visit questionnaire. Patients were asked to rate their physicians' style on a five-point scale, using the following questions: 1) If there were a choice between treatments, would this doctor ask you to help make the decision? [definitely yes to definitely no]; 2) How often does this doctor make an effort to give you some control over your treatment? [very often to never]? ; and 3) How often does this doctor ask you to take some of the responsibility for your treatment? (very often to not at all)? We created a scaled score by calculating a sum of these items. We then transformed this scale to range from 0 to 100 by subtracting the lowest possible value of the scale from the raw score, dividing the result by the maximum possible range of scores, and multiplying that result by 100. The mean SD, averaged across each physician's patients, for this transformed three-item scale along with its internal consistency reliability are presented in Table 1. The average interclass correlation among scores for each physician was relatively high (r = 0.62; P < 0.001). The average number of patients providing participatory decision-making style scores for each physician was 25.8 11.2. Table 1. Summary of Major Study Variables Questions on the personal and practice characteristics of physicians, from the clinician background questionnaire, included practice volume (measured as the number of outpatient visits that physicians reported having in a typical week of their main professional practice), participation in primary care and interviewing skills training during residency, and satisfaction with professional autonomy. Items were rated on a five-point scale, ranging from very satisfied to very dissatisfied. On the physician screening visit questionnaire, physicians were also asked how long they spent face to face with each study patient for the office visit. Because physicians might see the same volume of patients distributed over more or less concentrated blocks of time, we also measured time spent per patient to assess practice volume. Analyses using time spent per patient compared with practice volume produced highly similar results [11]. Analytic Strategy The analysis involved two stages. To minimize the effects of patient characteristics on physician style, we did a patient-level multiple regression analysis using patient-reported participatory decision-making style as the dependent variable and the patient's age, the patient's education level, the patient's sex, the patient's minority status, type of payment for health care, presence of eight selected common chronic conditions, the patient's perceived health status, and each physician's identification number (entered as dummy variables) as independent variables and covariates. We used individual physician identification numbers to remove the variation in physicians' participatory decision-making style that might have been due to unobserved physician characteristics. The results of this patient-level regression analysis [11] showed that patients who were older than 75 years of age or younger than 30 years of age, had less than a high school education, were not white, were male, had more comorbid conditions and poorer perceived health status, and reported a shorter relationship with the Medical Outcomes Study physician reported less participatory visits. Twenty-one percent of patients were seeing the Medical Outcomes Study physician for the first time, and another 6% were seeing the physician on an ongoing consultative basis. Because first and consultative visits were similarly distributed across the physician specialty groups and did not account for the observed differences in participatory decision-making style among the specialties, we retained these visits in the analysis. To account for differences in these patient characteristics in Medical Outcomes Study physicians' patient samples, we used this patient-level regression model to calculate an expected participatory decision-making style score for each Medical Outcomes Study physician. We then subtracted this expected score from the observed score (patients' actual style reports) for each physician. In all analyses, we have used the difference between this observed and the regression-generated expected participatory decision-making style score, transformed to range from 0 to 100 using the technique described above, as the dependent variable in statistical models. The use of the observed score minus the expected score results in a narrow numeric range but minimizes the variation in participatory decision-making style that would otherwise have been due to differences in Medical Outcomes Study physicians' patient panels. Observed differences in participatory decision-making style related to physician characteristics ranged from 33.2% to 80.6% of the adjusted participatory decision-making observed style score minus the expected style score's standard deviation. In the second stage of the analysis, we developed physician-level models, relating the observed score minus the regression-generated expected score to physician's age, sex, minority status, specialty, site of care, and type of practice (health maintenance organization, fee-for-service), entered as dummy variables, and statistical interactio