Original articleA shared decision-making communication training program for physicians treating fibromyalgia patients: Effects of a randomized controlled trial
Introduction
In chronic pain conditions, the quality of physician–patient communication can facilitate or impede effective treatment [1], [2], [3], [4], [5]. Fibromyalgia syndrome (FMS) is a chronic, pervasive, painful condition that is difficult to control; attempts to treat the syndrome often lead to frustration and resignation on the part of the patient and the physician alike.
According to American College of Rheumatology (ACR) classification criteria, FMS is characterized by pain affecting the whole musculoskeletal system and by well-defined tender points [6]. Additionally, patients often present with various vegetative and functional symptoms such as sleep disturbance, fatigue, dizziness, cognitive dysfunction, recurrent headaches, and irritable bowel syndrome; comorbidity with anxiety and depression is high [7], [8], [9], [10]. The prevalence of FMS is as high as 3.4% in European and North American countries, and women are seven to nine times more often afflicted than men [6], [11], [12]. The pathophysiological origins of FMS still remain widely unknown, and its etiology seems to be complex and multifactorial, involving somatic, psychological, and social components [13], [14], [15]. Unfortunately, there is as yet no cure available, so treatment options aim at alleviating symptoms [14].
Physician–patient interaction with FMS patients is often considered to be difficult [1], [2], [3], [4], [5]. Doctors characterize FMS patients as illness focused and demanding, and often find themselves in a dilemma due to the uncertainty inherent in FMS [4]. From patients' perspective, negative experiences during medical encounters include being met with skepticism and lack of comprehension; feeling rejected and ignored; and being belittled [1]. Friction in the patient–physician relationship is a common and frequently underestimated problem during FMS patients' consultations [5]. The inability to understand doctors' explanations and skepticism of the treatment can lead to an impaired physician–patient relationship and consequent dropout from treatment [16].
Given these therapeutic uncertainties and communication challenges, interactive principles inherent in “shared decision making” (SDM) may function as a model for more successful interactions between physicians and FMS patients.
SDM stresses the idea of partnership between physicians and patients when it comes to arriving at therapeutic choices in preference-sensitive decision situations. In physician–patient interaction, SDM bridges the gap between the assumption of exclusive responsibility for medical decisions, which is inherent in paternalistic approaches, and the concept of informed patient choice, which is inherent in approaches emphasizing patient autonomy [17], [18], [19], [20]. Since the 1990s, the awareness of SDM in the general public and among practitioners has risen, apparently due to greater access to medical information, increasing trends in medical “consumerism,” and a growing awareness of the patients' perspective [20].
An important element in SDM is the mutual exchange of information between doctor and patient. In an illness in which treatment options involve tradeoffs between the potential benefits and harm of therapy and uncertain outcomes, two kinds of knowledge are needed to manage an illness successfully: knowledge held by the physician, who is an expert in technical aspects of care, and knowledge held by the patient, who holds expert knowledge about one's unique circumstances (e.g., one's social situation, attitudes to risk, values, and preferences) [17], [21], [22]. When doctors consult according to SDM principles, they are careful to integrate their patients' perspective into the decision-making process. This requires certain key competencies, such as inviting patients explicitly into the decision-making process, checking patients' role preference, explaining the notion of medical equipoise and available options, checking patients' understanding, identifying and responding to any expectations and fears, and, finally, negotiating a treatment decision [19], [23].
Several positive effects of treatment in accordance with SDM principles have been demonstrated in studies on chronic disease: It may have beneficial effects on clinical outcome as measured physiologically, psychologically, functionally, and subjectively [24], [25], [26], [27], [28], [29]. SDM can also improve patients' satisfaction with their decisions and reduce their decisional conflicts [30].
To date, considerable attention has been devoted to the development and testing of SDM information materials for patients [31], [32], [33], but relatively little attention has been directed towards the systematic development and testing of ways to teach SDM transactional skills to physicians [30], [34], [35], [36]. In spite of widespread agreement among physicians that patient preferences be considered when treatment decisions are made, skills to perform SDM are often lacking [20], [37].
With interaction difficulties being obvious in FMS and with reasonable expectations that SDM might improve the situation, we found that it would be promising to implement an SDM intervention simultaneously focusing on FMS patients and their physicians.
The main objective of this study was to test whether the quality of physician–patient interaction from the patients' perspective could be improved by introducing principles of SDM to the physician–patient dyad in the management of FMS. We hypothesized that an intervention combining an information package for FMS patients with an SDM communication training program for physicians would lead to better physician–patient interaction when compared with a control group in which an information package was provided to patients but no special training was provided to physicians.
Section snippets
Study design
In a randomized controlled trial, we compared an SDM communication training group (hereafter referred to as SDM group for better readability) with an information-only group. All patients who were referred to the university's rheumatologic outpatient clinics for an initial consultation, with generalized muscle pain as main complaint, were asked for informed consent to participate in the study. A central coordination office ensured allocation concealment and carried out simple randomization of
Patients' characteristics
Of 164 eligible patients, 15 refused to participate, so 149 patients were randomized (n=76 to the SDM group and n=73 to the information-only group). In the SDM group, 14 patients cancelled the consultation, and 10 patients did not meet inclusion criteria. Therefore, 52 patients in the SDM group received the allocated intervention. After excluding eight patients due to missing questionnaires, data from the remaining 44 patients in the SDM group were analyzed.
In the information-only group, 11
Discussion
This study was undertaken in consideration of substantial interaction difficulties between FMS patients and their physicians [1], [2], [3], [4], [5]. Its purpose was to investigate whether SDM communication training for physicians could improve this situation.
The results of the study corroborate our main hypothesis that an SDM intervention—consisting of a communication training program for physicians combined with an information package for patients—is a possible way of achieving a more
Conclusion
The results of our study emphasize that FMS patients benefit from an SDM intervention that includes SDM communication training for their physicians.
When treated in accordance with the SDM concept, patients are significantly more satisfied with physician–patient interaction than are patients receiving only the information package. It will be important to investigate on follow-up whether there are any long-term benefits of SDM communication training.
Acknowledgments
The study was supported by a grant from the German Federal Ministry of Health (grant no. 217-4379-5/1) in the context of a research consortium on “Patients as Partners in the Medical Decision Making Process.”
The authors gratefully acknowledge Hilary A. Llewellyn-Thomas, PhD, for her critical review of this manuscript and helpful comments. They would also like to thank all participating patients and clinicians.
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