Complexity in shared decision making: a qualitative analysis of clinical encounters and patient/physician interviews

Background:  Shared decision making is a complex clinical activity, for which the most effective educational interventions are unclear. Cultural Historical Activity Theory (CHAT) can be utilized as a framework to help medical educators understand and teach shared decision making. The objective of this qualitative study was to utilize CHAT to explore, through analysis of clinical encounters and interviews, patient and provider perspectives of a medical decision-making process that included use of a decision aid mobile application (app). Methods: Female patients from age 17 to 45, who sought care at a contraceptive clinic between April and June 2019, and physicians providing care in the clinic, were recruited for this study. Patients utilized the decision aid app prior to the visit. The clinical encounter and semi-structured interviews with each patient and physician were recorded. Template analysis was used to analyze the transcripts with themes including elements of activity systems within CHAT, tensions within and between activity systems, and agency. Results: In total, 21 patients and eight providers participated in the study. Evidence of CHAT elements were identified for each patient-physician dyad. In analyzing occurrences of codes across transcripts, recurring contradictions and themes emerged, such as how the app is utilized as a mediating tool and the importance of patient and physician communities.     Conclusions: Through analysis of clinical encounters and focused interviews, patient and provider perspectives provided a unique understanding of the complex process of decision-making. These findings can assist educators in developing more effective teaching strategies that may lead to enhanced patient agency, effective relational agency, and successful shared decision making.