Surgeons’ views of decision making processes
During the interviews, the surgeons described patient and surgeon involvement in decision making related to the choice of surgical procedure. In general, most surgeons described a collaborative process to decision making in which the surgeon provided information about options and both parties expressed their preferences. For example,
“I think it’s important to give the woman the information and for them to make the decision … I do give them some of my experience”.
Surgeon 20, participated in RCT (decision board—usual care group)
“I think you want someone to help you sort through the issues and I think that’s the importance of, well not just ‘these are your two choices, take a couple of minutes I will be back, tell me which one you want’”.
Surgeon 8, unaware of PtDAs
When the surgeons perceived that both options were equally viable, the surgeons expressed that women should make the surgical choice.
“I think the patient has the right to make the choice and they should make the choice because I tell them whatever they choose I will be happy to do … because you are the one that has to live with your decision”.
Surgeon 18, used standard board PtDA during RCT, uses informal PtDA
While most surgeons viewed decision making as a collaborative process, only some surgeons used a PtDA. In the following sections, we describe surgeons’ views of enablers and barriers to the use of formal or informal PtDAs in practice.
Five themes emerged that were related to surgeon use of PtDAs. These were 1) surgical training and mentorship shapes how surgeons communicate with patients; 2) communication routines help ensure that important issues are remembered and stated; 3) there may be less “buy-in” to change communication routines as compared to surgical techniques; 4) surgeons’ views of the nature of PtDA outcomes inhibit their use; and 5) high confidence in surgeon’s own communication skills curtails searching for and using PtDAs.
Surgical training and mentorship shapes how surgeons communicate with patients
Surgeons described the influence of their surgical training, both in being exposed to informal PtDAs used by their mentors and the extent that they had opportunities to practice communication skills with patients during clinics in addition to the training received in the operating room. Several surgeons who were in practice for less than 5 years described that seeing a mentor use an informal PtDA influenced their use of a PtDA when they began independent practice.
“You pick and choose what aspects of practice you would like to emulate, and what you would like to incorporate into your own practice. So I worked with a couple of surgeons who did that routinely, the drawing part, and it made sense to me in terms of how you explain it, you have that consistency. So that’s why I choose to do it in that fashion”.
Surgeon 1, created own informal PtDA
In addition to describing their use of PtDAs during training, the surgeons related that surgical residency training has changed over time with a greater emphasis on practicing communication skills with patients in an office setting. Several surgeons who had been in practice for longer than 20 years relayed that, when they were residents, most of their time was spent in the operating room with little time spent in practicing communication skills with patients in office-based clinics. These surgeons discussed having to learn how to communicate to patients largely on their own when they assumed independent practice. The surgeons said that, currently, surgical residents spend time in clinics talking with patients although there may be variable encouragement by mentors to do so.
Communication routines help ensure that important issues are remembered and stated
All surgeons discussed the importance of developing communication routines with patients. They described that, early in their careers as independent surgeons, they did not feel comfortable with the way they explained information to patients. They spoke of taking a long time during consultations or being less than clear when explaining options to patients. Several surgeons who were relatively new in practice (less than 5 years) described that an informal PtDA that they had adopted after seeing one used by a mentor during residency helped them develop an effective communication routine. Other surgeons who had adapted a PtDA after using one during an RCT agreed. Having a pattern or routine way of explaining information helped to ensure that he/she would not forget to give patients important information about the risk of recurrent cancer or outcomes of treatment. For example,
“I think a lot of the things in medicine, be it surgery or whatever, is getting into a pattern of doing things the same way every single time so that you won’t forget something. And when I go through it I do my picture, I do the exact same thing every time, I know I’m not going to miss one of the risks or one of the outcomes or one of the side effects”.
Surgeon 13, used computer and standard board PtDAs during RCT, uses informal PtDA
Surgeons who were unaware of PtDAs corroborated the importance of communication routines. They commented that they developed their pattern of talking with patients through experience during practice. They said that a PtDA might be useful for someone new in practice. One surgeon who had been in practice for several years stated,
“I think it’s a good aid when you are first coming out in practice to make sure you have covered all your bases … But … what makes an expert an expert is pattern recognition. Most people that have been out long enough to have dealt with this problem, sort of know what to say and what not to say. And it may not be as big of a need with them as somebody who is freshly out [in practice] who are still trying to develop the way they are going to tell people their problems”.
Surgeon 6, never used a formal or informal PtDA
While the development of communication routines was important to surgeons, PtDAs did not necessarily fit well with established routines. The surgeons who had used a PtDA during an RCT said that it was difficult to fit the aid into their communication preferences and routines. They experienced difficulties adapting the PtDA to suit their own communication style. A surgeon who had participated in an RCT said,
“Even though I spend time with patients, it [using a PtDA] still is difficult because now you have a scripted message and doing scripting is difficult. Because everyone is going to do things differently. You can see the same play at [a] festival and you can see it on the big screen, it’s the same play but it’s not the same”.
Surgeon 15, used standard board PtDA during RCT
Another surgeon agreed saying,
“For me I find it [PtDA] very cumbersome and it depends on your personality too. I’m not the one who picks up a paper and explain things like that. So usually how I do [it] is I have my own, I call [it] my own decision board when I see a patient, this is what I go through and then I usually draw a couple of the drawings”.
Surgeon 18, used standard board PtDA during RCT, uses informal PtDA
Less “buy-in” to change communication routines as compared to surgical techniques
Several surgeons commented on instances when they had made changes to incorporate a new surgical technique in their everyday practice. They appeared to be less motivated to make changes to their communication routines.
“I think if it’s a surgical technique, if it’s technical driven, we’re all on it, it’s like yeah, let’s try it, let’s do it. Or show me about that or how does that work? And then we’re interested. When it’s like well now you can use this to discuss this option with your patient, I don’t think people are going to dismiss it, I’m just not certain what the buy- in is going to be”.
Surgeon 13, used computer and standard board PtDAs during RCT, uses informal PtDA
Nevertheless, several surgeons had made changes to their communication routines by adapting a previously developed formal PtDA. However, the above quote and the one that follows suggest that the nature of change, i.e., surgical techniques versus communication skills, may be an issue that may influence the adoption of an innovation.
“[Surgeons] will be more motivated to seek out improvements in surgical techniques than they would be with communication skills”.
Surgeon 19, unaware of PtDAs
Views of the nature of PtDA outcomes inhibit their use
Several surgeons indicated that the outcomes of PtDAs were not compelling enough to change their practice. They seemed to be more interested in innovations in surgical techniques that might affect surgical outcomes. For example, a surgeon who was previously unaware of PtDAs said,
“Something like this [PtDA] it might make my job a little bit easier or it make it a little easier to get that information translated across. But I don’t see it as making a big difference in the outcome or the practices. So I’ve been less interested or less enthused about going and looking for the information”.
Surgeon 7, unaware of PtDAs
“You can show all the positive results but it’s hard to get people to change their practice and their way of doing things, for that kind of thing where it doesn’t matter. But … if all of a sudden, a study came out that appendectomy was dangerous, well then of course everybody is going to change their practice but this isn’t quite as dramatic”.
Surgeon 14, uses informal PtDA
High confidence in one’s own communication skills curtails searching for or using PtDAs
Several surgeons commented that they were confident in their ability to communicate information to patients. They did not perceive a need to look for or use a PtDA.
“I think that I do an okay job right now so I haven’t really sought out to find this [PtDA], which would be different than when we were starting doing sentinel nodes [surgical technique]. I made a point of learning [about sentinel lymph node biopsy] myself out in the community … because I thought that was a significant change in practice”.
Surgeon 7, unaware of PtDAs
Related to the surgeon’s confidence in his or her communication skills was the perception that patients understood information about treatment options conveyed by the surgeon. For example,
“I am kind of focussed and cover everything and then at the end of our discussion most of the time the patients say, well they checked through [and said], ‘I have no questions left’”.
Surgeon 9, participated in RCT (standard board—usual care group)
Many surgeons shared this view. For example,
“Typically I feel my patients are very well informed and they know what is going on and they know what their choices are. I have never felt the urge to look for anything [PtDA]”.
Surgeon 8, unaware of PtDAs
“Well I think the patient is informed. We did not find patients don’t understand or patients have any unanswered questions with what we are doing. Obviously always there can be improvement to any practice, but what we are currently doing, I think patients are quite happy with that”.
Surgeon 12, unaware of PtDAs