Do patients' communication behaviors provide insight into their preferences for participation in decision making?

Background. The Institute of Medicine report "Crossing the Quality Chasm" encourages physicians to tailor their approaches to care according to each patient's individual preferences for participation in decision making. How physicians should determine these preferences is unclear. Objective. The objective of this study is to assess whether judgments of patient communication behaviors, either globally or individually, can yield insight into patient preferences for participation in decision making. Methods. Using questionnaire responses to 3 items about the desired level of participation in decision making from a communication study involving 886 audiotaped visits between older patients and surgeons, the authors purposively selected 25 patients who preferred a large role and 25 who preferred a small role in decision making. Two independent raters listened to the audiotapes and coded them for the presence of 7 communication behaviors (question asking, information behavior, initiating, statements of preference, processing, resistance, deference). On the basis of their listening and coding, raters judged patient preferences for participation in decision making. Results. Neither rater accurately judged preferences for participation in decision making beyond chance agreement (kappa statistics: rater 1 = 0.16, rater 2 = 0.20). Interrater reliability for the communication behaviors was also generally poor. Area-under-the-curve values for all communication behaviors hovered around 0.50, indicating that none of the behaviors had adequate power to discriminate between patients preferring large versus small a roles. Conclusion. Patient preferences for participation in decision making cannot be reliably judged during routine visits based on judgments of patient communication behaviors, Engaging patients in a discussion of preferences for decision making may be the best way to determine the role each wants to play in any given decision.