Article Text

What is a medical decision? A taxonomy based on physician statements in hospital encounters: a qualitative study
  1. Eirik H Ofstad1,
  2. Jan C Frich2,
  3. Edvin Schei3,
  4. Richard M Frankel4,
  5. Pål Gulbrandsen5
  1. 1The Research Centre, Akershus University Hospital, Lorenskog, Norway
  2. 2Institute of Health and Society, University of Oslo, Oslo, Norway
  3. 3Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
  4. 4Indiana University School of Medicine, VA HSR&D Center of Excellence, Roudebush VA Medical Center, Indianapolis, Indiana, USA
  5. 5Institute of Clinical Medicine, Campus Ahus, University of Oslo, Lorenskog, Norway
  1. Correspondence to Dr Eirik H Ofstad; eirikofstad{at}


Objective The medical literature lacks a comprehensive taxonomy of decisions made by physicians in medical encounters. Such a taxonomy might be useful in understanding the physician-centred, patient-centred and shared decision-making in clinical settings. We aimed to identify and classify all decisions emerging in conversations between patients and physicians.

Design Qualitative study of video recorded patient–physician encounters.

Participants and setting 380 patients in consultations with 59 physicians from 17 clinical specialties and three different settings (emergency room, ward round, outpatient clinic) in a Norwegian teaching hospital. A randomised sample of 30 encounters from internal medicine was used to identify and classify decisions, a maximum variation sample of 20 encounters was used for reliability assessments, and the remaining encounters were analysed to test for applicability across specialties.

Results On the basis of physician statements in our material, we developed a taxonomy of clinical decisions—the Decision Identification and Classification Taxonomy for Use in Medicine (DICTUM). We categorised decisions into 10 mutually exclusive categories: gathering additional information, evaluating test results, defining problem, drug-related, therapeutic procedure-related, legal and insurance-related, contact-related, advice and precaution, treatment goal, and deferment. Four-coder inter-rater reliability using Krippendorff's α was 0.79.

Conclusions DICTUM represents a precise, detailed and comprehensive taxonomy of medical decisions communicated within patient–physician encounters. Compared to previous normative frameworks, the taxonomy is descriptive, substantially broader and offers new categories to the variety of clinical decisions. The taxonomy could prove helpful in studies on the quality of medical work, use of time and resources, and understanding of why, when and how patients are or are not involved in decisions.

  • Medical decision making
  • Hospital medicine
  • Patient-physician communication
  • Shared decision making
  • Physician behaviour
  • Communication

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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