Implications for practice and policy

Policymakers are looking for ways to further promote patient centered care and shared decision making (Beach et al., 2007; de Haes, 2006; Fried, 2016; Legare &

Witteman, 2013). Primary care has been credited with improving quality of care particularly in terms of continuity, adherence, fewer visits to the emergency department, hospitalizations and lower costs (O'Malley, Rich, Maccarone, DesRoches, & Reid, 2015).

Yet, there is room for further study on how primary care teams are working to meet patients’ needs (O'Malley et al., 2015). One way of improving the quality of ‘good clinical practice’ is through shared decision making (Elwyn, Tilburt & Montori, 2012).

SDM is encouraged because of its potential to improve the quality of care delivered, by aligning care with patient’s preferences and values (Oshima Lee & Emanuel, 2013) and

187 by reducing practice variation (Stiggelbout, 2012). SDM has the potential to improve knowledge, adherence, continuity, decisional conflict, satisfaction and in some instances, functional status and cost (Elwyn et al., 2000; Charles et al., 1997; Oshima Lee &

Emanuel, 2013; Veroff et al., 2013). However, the overwhelming reason that SDM is advocated as a quality improvement tool is because it is the right way to practice medicine (Elwyn et al., 2012) for a particular patient (Kunneman & Montori, 2016). Yet, in practice SDM has not become embedded in routine care (Elwyn et al., 2014; Elwyn, Tilburt & Montori, 2012; Frosch et al., 2012; Frosch et al., 2011; Legare & Witteman, 2013). As such, further research on implementing SDM is recommended (Elwyn, Frosch

& Kobrin, 2016). Previous research has relied on impractical and time-consuming reviews of encounters or survey data to measure SDM (Durand et al., 2015). The authors of this recent study questioned the efficacy of incentives for implementation based on the use of shared decision aids whose effect on SDM is difficult to measure (Durand et al., 2015). Instead, the authors suggest that further study is needed in communication and the culture surrounding the clinician-patient relationship (Durand et al., 2015). Others suggest that qualitative studies could be a complementary research methodology to ongoing big data and survey research studies (Cheshire, 2016). This qualitative study found that respect and shared decision making are related in ways that influence the culture of the clinician-patient relationship. Participants also described respectful clinical

188 encounters influencing their continuity of care, adherence and satisfaction with the quality of the clinical experience. Accordingly, future implementation efforts should consider respect as well as SDM, given that respectful relationships are valued throughout the decision-making process.

Respect has consequences for health outcomes (Beach et al., 2006; Beach et al., 2005; Bendapudi et al., 2006; Clucas & St Claire, 2010; Quigley et al., 2014). Here is how it matters for quality. Patients perceiving themselves to be treated with respect led to higher levels of satisfaction, adherence, preventive care (Beach et al., 2005) and

familiarity with their clinician (Beach et al., 2006). In this study, clinicians were described as respectful when they exhibited certain attitudes and behaviors. Yet, respectful care was also described through less tangible and emotional aspects of the encounter. Both sets of characteristics of respect had consequences for satisfaction, continuity and adherence. As such, clinic administrators aiming to improve quality metrics should consider training clinicians in the multiple dimensions of respect described in this study. Clinicians could be trained on respectful communication styles that go beyond listening, explaining and understanding. To begin, clinicians could be reminded how important it is to ‘look again, to regard’ the individual in the room as more than a patient, as a person in a unique social context. This involves getting to know the patient beyond their medical diagnosis. Thereafter, to be respectful, clinicians need to

189 validate patient’s concerns and adapt care to meet those concerns. Clinicians could also be reminded of the importance of encouraging their patient’s agency in the encounter. By creating spaces for patients to set the agenda and direct their care, clinicians will be respectful. This can be achieved by ensuring that both patients and clinicians feel

comfortable in the encounter. It may be more difficult to teach the affective elements of respect that participants ‘saw’ during video reflexivity. Especially with a concept like respect that may be difficult to grasp if it is not related to in situ care practices. Using VRE as quality improvement tool could be helpful for clinicians to relate their everyday practices to the conceptual descriptions of respect, particularly the intangible, affective dimensions. VRE has previously been used as a quality improvement tool by Kaiser Permanente (Neuwirth et al., 2012). Moreover, the third phase of VRE, which was not undertaken in this study, specifically aims to effect immediate practice change. The VRE methodology itself facilitates ‘exnovation’ or innovation from within (Iedema et al., 2013). It is the clinical teams themselves that recognize the everyday best practices via the moving images in their reflexivity sessions. By seeing and hearing how participants perceive their encounters, key stakeholders may be driven to recommend practice improvements. One can imagine that improvements may include access to scheduling that is presently outside of the control of clinicians, putting a ceiling on the number of

190 patients in each panel, allocating administrative time to follow-up with patients and to provide the extra care that is presently not compensated.

A further aspect to training might emphasize skills to deal with emotional work and burnout in primary care encounters. Health care within a broader institutional frame has been shown in this study to be rife with tensions leaving clinicians conflicted and on the verge of burn out. Acknowledging that clinicians who challenge this tension are putting in extra effort, which goes unrecognized and uncompensated, may be one way in which institutions can humanize care and minimize the consequences for caring

clinicians.

Time constraints were shown to lead to efficient and respectful behaviors but result in additional tensions for clinicians. Addressing this tension from competing priorities for clinicians may require further research. Restructuring the scheduling of follow-up appointments so that the priority is shifted from revenue sources to relationship building might give clinicians a greater sense of control over their working environment.

Fostering a partnership between patients and clinical teams has been recommended in the literature (Montori et al., 2006; Richards et al., 2013). In this study, seeing multiple members of a clinical team was not respectful to patients who favored longer-term

continuous relationships with one clinician. How primary care clinics can be re-structured so that clinicians can see a smaller panel of patients is worthy of further study. Finally,

191 institutions that are heavily committed to evidence-based guidelines may be

recommending treatments for patients that patients are resisting. When this occurs, the clinic can check the quality box that they have complied with the ‘best’ evidence available while the patient may be labeled non-compliant (Mulley, Trimble, & Elwyn, 2012). I believe that more respectful encounters could enable participants to feel comfortable enough to resolve these discrepancies at the time of the encounter and therefore positively affect adherence rates.

Future research should consider respect as a factor in an expanded SDM measure.

The OPTION scale, described as a measure of ‘the extent to which healthcare

professionals involve patients in decisions within clinical consultations’ (Elwyn et al., 2003) focuses on clinician behaviors, and has been used extensively to measure SDM.

This measure persists even as newer conceptual models of SDM (Elwyn et al., 2016;

Montori et al., 2006) highlight the collaborative and participatory nature of the deliberative process, suggesting that the role of the patient should also be considered.

Other measures have emerged to address this imbalance in the OPTION scale, such as the SDM-Q-9 theoretically based measure (Kriston et al., 2010) which allows patients

themselves to measure clinician behavior, and scales that acknowledge the dyad in the encounter (Kenny et al., 2010; Melbourne, Sinclair, Durand, Legare, & Elwyn, 2010).

These scales have not received the uptake that the OPTION scale has. The OPTION scale