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Physician-identified barriers to and facilitators of shared decision-making in the Emergency Department: an exploratory analysis
  1. Elizabeth M Schoenfeld1,2,
  2. Sarah L Goff1,3,
  3. Tala R Elia2,
  4. Errel R Khordipour4,
  5. Kye E Poronsky2,
  6. Kelly A Nault2,
  7. Peter K Lindenauer1,
  8. Kathleen M Mazor5,6
  1. 1 Institute of Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA
  2. 2 Department of Emergency Medicine, University of Massachusetts Medical School - Baystate, Springfield, Massachusetts, USA
  3. 3 School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, USA
  4. 4 Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York, USA
  5. 5 Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
  6. 6 Meyers Primary Care Institute, Worcester, Massachusetts, USA
  1. Correspondence to Dr Elizabeth M Schoenfeld, Emergency Medicine, Baystate Medical Center, Springfield, MA 01199, USA; elizschoen{at}


Objectives Shared decision-making (SDM) is receiving increasing attention in emergency medicine because of its potential to increase patient engagement and decrease unnecessary healthcare utilisation. This study sought to explore physician-identified barriers to and facilitators of SDM in the ED.

Methods We conducted semistructured interviews with practising emergency physicians (EP) with the aim of understanding when and why EPs engage in SDM, and when and why they feel unable to engage in SDM. Interviews were transcribed verbatim and a three-member team coded all transcripts in an iterative fashion using a directed approach to qualitative content analysis. We identified emergent themes, and organised themes based on an integrative theoretical model that combined the theory of planned behaviour and social cognitive theory.

Results Fifteen EPs practising in the New England region of the USA were interviewed. Physicians described the following barriers: time constraints, clinical uncertainty, fear of a bad outcome, certain patient characteristics, lack of follow-up and other emotional and logistical stressors. They noted that risk stratification methods, the perception that SDM decreased liability and their own improving clinical skills facilitated their use of SDM. They also noted that the culture of the institution could play a role in discouraging or promoting SDM, and that patients could encourage SDM by specifically asking about alternatives.

Conclusions EPs face many barriers to using SDM. Some, such as lack of follow-up, are unique to the ED; others, such as the challenges of communicating uncertainty, may affect other providers. Many of the barriers to SDM are amenable to intervention, but may be of variable importance in different EDs. Further research should attempt to identify which barriers are most prevalent and most amenable to intervention, as well as capitalise on the facilitators noted.

  • emergency department
  • emergency care systems, emergency departments
  • qualitative research

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  • Contributors EMS, PKL, SLG and KMM conceived the study, designed the trial and obtained research funding. EMS and SLG supervised the conduct of the trial and data collection. EMS, TRE, KEP and KAN undertook recruitment of participating centres and patients and managed the data, including quality control. EMS, ERK and KEP analysed the data. EMS drafted the manuscript, and all authors contributed substantially to its revision. EMS takes responsibility for the paper as a whole.

  • Funding This study was funded by a grant from AHRQ (1R03HS024311-01). Also, the project described was supported by the National Center for Advancing Translational Sciences, the National Institutes of Health (award number UL1TR001064).

  • Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

  • Competing interests None declared.

  • Ethics approval This study was reviewed by the Baystate Medical Center IRB, Springfield, MA, USA, and determined to meet the criteria for exemption.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.