ACP American College of Physicians - Internal Medicine - Doctors for Adults

Effective Clinical Practice

Patient Decision Making: In Search of Good Decisions

Effective Clinical Practice, July/August 1999.

As patients take (or are expected to take) increasing responsibility in decisions about their health care, both patients and physicians may wonder about the quality of the decisions being made. Although much progress has been made in developing analytic methods around which to model decisions (e.g., decision analysis), less work has been devoted to understanding how patients really make them. To begin to address this largely unexplored area, we have devoted this issue of ecp to patient decision making.

Assessing patient decision making is difficult because what we should be measuring is not clear. For example, how do we know if we have achieved informed consent? How do we know what patients should know and whether they have understood what we have told them? Judging decisions by compliance with physician recommendations cannot be the answer, because the patient's values may differ from those of the doctor. The patient's overall satisfaction with care is also an inadequate measure because it is influenced by outcomes (i.e., a good decision can still have a bad outcome). To learn whether patients are making good health care decisions and to determine the effectiveness of the various interventions intended to improve these decisions (e.g., educational materials, Web sites, videos, decision aids), evaluators need to develop measures of a good decision. In this issue, the work by O'Connor and colleagues,1 which evaluates decision aids, is an important first step.

To help define the critical components of a measure to assess the quality of a patient's decision, we asked a diverse group to contribute to this issue of ecp and respond to the question, "What is a good decision"? Their responses can be found on the following pages. These essays highlight many of the fundamental issues inherent in patient decision making: What is the role of the physician? the patient? others? Which decisions merit this kind of special attention? How much information do patients need or want? Will they be able to use the information we give them? What happens when doctors and patients disagree about the best course of action? Although several concrete suggestions are offered, many of the issues remain open and will require extensive work. We encourage you to ask yourselves, "What is a good decision?" We look forward to hearing your thoughts.


1. O'Connor AM, Drake ER, Fiset V, Graham ID, Laupacis A, Tugwell P. The Ottawa patient decision aids. Effective Clinical Practice. 1999;2:16370.