Instruments to assess the perception of physicians in the decision-making process of specific clinical encounters: a systematic review

Background The measurement of processes and outcomes that reflect the complexity of the decision-making process within specific clinical encounters is an important area of research to pursue. A systematic review was conducted to identify instruments that assess the perception physicians have of the decision-making process within specific clinical encounters. Methods For every year available up until April 2007, PubMed, PsycINFO, Current Contents, Dissertation Abstracts and Sociological Abstracts were searched for original studies in English or French. Reference lists from retrieved studies were also consulted. Studies were included if they reported a self-administered instrument evaluating physicians' perceptions of the decision-making process within specific clinical encounters, contained sufficient description to permit critical appraisal and presented quantitative results based on administering the instrument. Two individuals independently assessed the eligibility of the instruments and abstracted information on their conceptual underpinnings, main evaluation domain, development, format, reliability, validity and responsiveness. They also assessed the quality of the studies that reported on the development of the instruments with a modified version of STARD. Results Out of 3431 records identified and screened for evaluation, 26 potentially relevant instruments were assessed; 11 met the inclusion criteria. Five instruments were published before 1995. Among those published after 1995, five offered a corresponding patient version. Overall, the main evaluation domains were: satisfaction with the clinical encounter (n = 2), mutual understanding between health professional and patient (n = 2), mental workload (n = 1), frustration with the clinical encounter (n = 1), nurse-physician collaboration (n = 1), perceptions of communication competence (n = 2), degree of comfort with a decision (n = 1) and information on medication (n = 1). For most instruments (n = 10), some reliability and validity criteria were reported in French or English. Overall, the mean number of items on the modified version of STARD was 12.4 (range: 2 to 18). Conclusion This systematic review provides a critical appraisal and repository of instruments that assess the perception physicians have of the decision-making process within specific clinical encounters. More research is needed to pursue the validation of the existing instruments and the development of patient versions. This will help researchers capture the complexity of the decision-making process within specific clinical encounters.


Background
Practising medicine involves making decisions at all stages of the clinical process [1]. Although a great deal of varied terminology is used to describe doctors' thinking, the term "decision-making process" is used extensively in the medical and healthcare literature [2]. The decisionmaking process is broadly defined as global judgements by a clinician about the appropriate course of action and is said to be unspecified, as a number of processes may produce a decision [3]. In clinical settings, it is also understood as the use of diverse strategies to generate and test potential solutions to problems that are presented by patients and involves using, acquiring and interpreting the indicators and then generating and evaluating hypotheses [4]. Processes or strategies that will be used may be based on what the clinician was taught, his or her own representation of the evidence supporting each course of action, or the prevailing practice in a given institution [4].
In recent years, there has been a growing interest in new representations of the clinical decision-making process that better address its complexity within specific clinical encounters. Indeed, providing medical care to a patient is now increasingly considered a dynamic and interactive process known as "shared decision-making" [5][6][7]. Characteristics of shared decision-making include that at least two participants, clinician and patient, be involved; that there be a two-way exchange not only of information but also of treatment preferences; that both parties take steps to build a consensus about the preferred treatment; and that an agreement be reached on the treatment to be implemented [5]. Shared decision-making includes the following components: establishing a context in which patients' views about treatment options are valued and deemed necessary, transferring technical information, making sure patients understand this information, helping patients base their preference on the best evidence; eliciting patients' preferences, sharing treatment recommendations, and making explicit the component of uncertainty in the clinical decision-making process [8].
Shared decision-making does not exclude a consideration of the values and preferences of the physician and occurs through a partnership in which the responsibilities and rights of each of the parties and the benefits for each party are made clear [9]. Given the recognition that patient-physician interactions and by extension, clinical decisionmaking processes, are dynamic and reciprocal in their nature, it is surprising to find little systematic evaluation of the physicians' perspective of this entity [10]. Consequently, there has been a renewed interest in capturing the perspective of physicians of the decision-making process within specific clinical encounters. Therefore, the aim of this systematic review was to identify instruments that assess the perception of physicians of the decision-making process within specific clinical encounters.

Search strategy
Covering all years available (to April 2007), we conducted an electronic literature search of the following databases: PubMed, PsycINFO, Current Contents, Dissertation Abstracts and Sociological Abstracts. Three information specialists were consulted to help develop, update and run the search strategy. The following MeSH terms and free text words were used to create specific search strategies for each database: "decision making", "physicians", "health personnel", "doctors", "practitioners", "health personnel attitudes", "measurement", "questionnaire", "psychometrics" and "psychological tests". We included titles of publications and their respective abstract in English or French that potentially included an eligible instrument. Initially, if a dissertation abstract was found along a publication, both were kept. We also contacted 10 experts in the field (list available from authors) and contacted corresponding authors of included instruments. Lastly, we reviewed bibliographies of the included instruments. Once we included an instrument, we conducted an electronic search of the first author.

Selection criteria
All of the searches were downloaded to a reference database for initial screening of titles and abstracts by a single member of the review team. Prior to screening, duplicates were removed from the database. Titles of publications and their respective abstract reporting editorials, letters, surveys, clinical vignettes or the completion of an Objective Structured Clinical Examination or the evaluation of a simulated patient were excluded. After the initial screening, if detailed information about the titles of publications and their respective abstract was questionable, the full text of these publications was sought. Then, two reviewers independently appraised these publications to identify ones that reported on the use or development an eligible instrument. Discrepancies between the two reviewers were resolved through discussion.

Identification of eligible instruments
The following inclusion criteria were applied: 1) a selfadministered instrument was presented; 2) the instrument evaluated the perspective of physicians, including residents, of the decision-making process within specific clinical encounters, 3) the collection of data occurred after a specific clinical encounter in a 'real' clinical setting; 4) the report included sufficient description to permit critical appraisal of the instrument (for example, the instrument was provided as an appendix or we were able to get a copy from the author); and 5) there were quantitative results following the administration of the instrument. An instru-ment was defined as a systematic procedure for the assignment of numbers to aspects of objects, events or persons as indicated by its construction, administration and scoring procedure according to prescribed rules [11].
The outcomes of interest included the perception of physicians of the decision-making process within specific clinical encounters as well as the outcome of the decision itself such as satisfaction with the decision. The decisionmaking process was defined in an inclusive manner as global judgements by a physician about the appropriate course of action [3]. An instrument was deemed eligible if one of its sub-scales or some of its items tapped into the outcomes of interest.

Data extraction
The data extraction form, derived from McDowell (1987) [12], covered characteristics of the source of information and characteristics of the instrument itself, such as name of the instrument, origin of first author, main purpose, description of the instrument, characteristics of the response scale, presence of a corresponding patient instrument, development procedures, conceptual/theoretical foundation, validity, reliability (e.g. internal consistency) and responsiveness of the instrument.
A conceptual framework was considered to be used if the author referred to a set of concepts and the propositions that integrate them into a meaningful configuration [13]. A theory was deemed to be used if the author referred to a theory, defined as a series of statements that purport to account for or characterize some phenomenon with a much greater specificity that a conceptual framework [13]. Otherwise, the nature of the source of references used by the author was used to identify a broad conceptual basis.
Content validity (i.e. the extent to which all relevant aspects of the domain or area that is being measured are represented in the instrument), construct validity (i.e. the extent to which the instrument relates to other tests or constructs in the way that was expected) and criterion validity (i.e. the extent to which the instrument relates to a gold standard to which it is compared) were also assessed [14]. Responsiveness (i.e. the extent to which the instrument measured change within persons over time) was also assessed [15].
Using the Science Citation Index, we assessed how many times the included instruments had been cited in subsequent published research in French or English. Lastly, for each instrument, we assigned one main evaluation domain defined as a subjective interpretation by the reviewers of the main construct that the instrument was assessing. Sources of disagreement were discussed and resolved by consensus and only consensus data was used. Data extraction was completed by two members of the team.

Quality assessment
The quality of reporting of the included studies was assessed by two reviewers independently, using a modified version of the following instrument, Standards for Reporting of Diagnostic Accuracy (STARD) [16][17][18]. The original STARD contains 25 items pertaining to study question, study participants, study design, test methods, reference standard, statistical methods, reporting of results and conclusions. However, because we were interested in instruments assessing the perception of physicians of the decision-making process within specific clinical encounters, we added one more item under the section "statistical methods." This new item assessed if the authors of the included instrument had taken into account that one physician could only contribute to one questionnaire for the statistical analyses used to provide evidence on its reliability and validity (i.e., the non-independence of data). For each instrument, we chose one main study. In instruments for which more than one report was included, we chose the one that reported the most details on the development and psychometrics of the instrument in its most recent version.

Included instruments
The initial search resulted in 3431 records ( Figure 1). From these, 192 records that were in a language other than French or English, and 138 duplicates were removed. After applying our eligibility criteria, 218 full text articles were retrieved for detailed evaluation. Twenty-six instruments (67 articles) were potentially eligible of which a further 15 (28 articles) were excluded because they were not designed to collect data for a specific clinical encounter . Therefore, 11 instruments (39 articles) were included . We were able to get access to a published version or a copy of all included instruments.
Based on the Science Citation Index, nine instruments had been cited at least once in subsequent research pub-lished in French or English with the older ones being more likely to be cited more often (Spearman r = -0.68; p = 0.03).

Description (number of dimensions and items)
Response scale

Number of citations
Physician Satisfaction Scale (Shore, 1986) [54,76,83] Department of Preventive, Family and Rehabilitation Medicine -To study physician satisfaction in encounter-specific situations.
-Non-specific clinical problem.
-Clinical and educational (the authors thought that the use of this instrument could serve as a possible pathway to changing providers' behaviour through self-awareness).
-2 dimensions/16 items -understanding the patient's problem, having a sense that the patient understood what the physician said, affective reactions to the interaction with the patient and satisfaction of physician and patient were included.

pt Likert
No 14 Mental Work-Load Instrument (Bertram, 1992) [55,56,59,74] Department of Social and Preventive Medicine -To assess the subjective experience or cost incurred by a physician in performing patient care tasks that reflect the combined effect of demands imposed by task requirements, the support personnel, information and equipment resources provided the physician's skill and experience, strategies adopted by the physician, effort exerted, and emotional responses to the situation.
-Non-specific clinical problem.
-Quality improvement (the authors aimed at taking into account the cognitive processes involved in physician work so that physicians could be trained or patient care settings structured to minimize the physician limitations and improve their performance as well as the productivity of the organization).
-5 dimensions/6 items -mental effort, physical effort, difficulty, performance and psychological stress (each with 1 item except performance with 2).

No 8
Questionnaire concerning the sources of frustration physicians experience in their work with patients (Levinson, 1993) [72] Department of Medicine -To identify specific aspects of patient visits that cause physician frustration and to develop a self-assessment instrument for physicians -Non-specific clinical problem.
-Quality improvement (the authors thought that through reflection, this instrument would assist physicians to identify areas of their experience with patients that are frustrating and that need improvement and that ultimately, patient care would be improved).
-7 dimensions/25 items -lack of trust, too many problems, feeling distressed, lack of adherence, lack of understanding, demanding/controlling patients, and special problems (each with 3-4 items).

pt Likert No 49
Physician Satisfaction Questionnaire (Suchman, 1993) [84,85] Department of Medicine and Psychiatry -To assess physician satisfaction with primary care office visits in encounter-specific contexts, and to identify determinants of physician satisfaction.
-Non-specific clinical problem.
-Research, clinical and educational (the authors thought that this instrument could be used to guide the preparation of future physicians with skills, knowledge and attitudes they will need to practice in a manner that is satisfying both to their patients and to themselves).
-4 dimensions/20 items -quality of the patient doctor relationship, adequacy of the data collection process during the visit, appropriate use of time during the visit and patient's non-demanding, cooperative nature.
-Intensive Care Unit (ICU) settings (the author assumed that it could be used in non-ICU settings or to refer to other type of patient care decisions as well).
-Research and quality improvement (the author thought ultimately, responses to this instrument could be linked to patient and provider outcomes).
-2 dimensions/9 items -level of collaboration between the physician and the nurse in making the decision (7 items) and satisfaction with the decision and decision-making process (   Content validity: -efforts were put into the development phase of the instrument to ensure validity of the items (x consultation of experts) Construct validity: -factor analysis confirms 7 factors. Mean respective factor loading for all items is 0.68 (SD = 0.10) -the instrument discriminated between younger and older physicians (i.e. younger physicians had higher scores on all subscales meaning they felt more frustrated than the older physicians) and between primary care physicians and specialists on two subscales: too many problems and feeling distressed (i.e. primary care physicians had higher score than specialists). Greater time spent in primary care was associated with higher scores on several subscales. Convergent validity was shown with physicians' general level of satisfaction and the percentage of visits they reported as being frustrating correlating with higher scores on most subscales.

Not provided
Physician Satisfaction with Primary Care Office Visits (Suchman, 1993) [84,85] The development of this instrument was achieved within a larger initiative, "The Collaborative Study of Communication Dynamics". This initiative was organized by the Task Force on Doctor and Patient of the Society of General Internal Medicine that was conducted at 11 sites in North America. Members of this group included well-known experts in the field of patient-doctor interaction and communication. The instrument was tested with 124 physicians (35 residents, 60 general internists and 3 family physicians) who saw a total of 550 patients.
Not clear Content validity: face validity is considered in that the items of the scale share common ground with previously published measures Construct validity: -factor analysis reveals 4 distinct factors, but since these construct domains were not predicted at first in a theoretical framework, this analysis provides weaker support for the construct validity of the instrument -a number of patient characteristics were significantly associated with the sub-scales. For example, emotional distress of patients was negatively correlated with all satisfaction dimensions except the time dimension. Satisfaction with the patient doctor relationship sub scale was the most important determinant of global satisfaction (R 2 = 39%) while the adequacy of data collection process was the second most important determinant (R 2 = 4%). Note: Non-independence of observations was taken into account: a bootstrapping technique was used to create 10 replication samples of n = 124 and factor analysis was then performed 10 times.     [77][78][79][80][81][82].
On the basis of a literature review, two domains were identified: patient's health status and the office visit. Two experts, a clinical psychologist and a gastroenterologist, were provided with a list of items recorded from the literature review and asked to select the top 10 items thought to be relevant to making treatment decision. A consensus was reached after a brief discussion.
Broad domain of patient-physician discordance.
Content validity: Based on the literature review and two experts. For construct and criterion validity, data are provided only for the combination of the physician's and patient's questionnaires Data are provided only for the combination of the physician's and patient's questionnaires.
Mutual Understanding Scale (Harmsen, 2005) [68] This instrument was developed based on Kleinman's theory, a method of phasing or structuring of consultations by the physician (S.O.A.P. method) and a consensus method of decision-making called the Nominal Group Technique or expert-panel meeting Kleinman's theory about the influence of culturally determined views on health beliefs and the necessity for physician and patient to demonstrate these views by exchanging explanatory models during the consultation. Content validity: By using questions about different consultation aspects, known as GP standard of structuring the consultation, the complete consultation was covered. For construct and criterion validity, data are provided only for the combination of the physician's and patient's questionnaires Data are provided only for the combination of the physician's and patient's questionnaires. Reasons for Treatment Selection Questionnaire (Linden, 2006) [73] N/A Action theory N/A N/A Questionnaire concerning the doctor-patient communication skills [58] This pair of instruments was developed based on the Patient Centered Care method [98] and theories in the field of communication. Its authors drew on existing instruments and the communication skills expertise of 2 members of the steering group to create the pair of instruments. The initial instruments were administered to 4 specialists and 3 family doctors in Ontario, Canada, who, along with their patients, provided feedback. The final pair of instruments was tested with 16 family doctors and 22 specialists from 3 Canadian provinces. These doctors recruited a total of 1881 patients.
Patient Centered Care method [98] and theories in the field of communication.
Content validity: based on existing instruments and the communication skills expertise of 2 members of the steering group to create the pair of instruments. Construct validity: -Factor analysis was performed by using the whole set of 38 items (19 items in the doctor's questionnaire plus 19 items in the patient's questionnaire) to ascertain whether the patient and doctor items were 2 separate factors. Then by examining the data for patient and doctor separately, the authors ascertained if the process and content items accounted for separate factors. The items on all 3 datasets (i.e. 19 items from the patient data alone, 19 items from the doctor data alone, and the combined dataset of 38 items) were separately intercorrelated using Pearson product) moment correlations.  we could not find evidence of validity and reliability data published in French or English [73].

Discussion
We believe that the results of this systematic review are important. First, they indicate that there is an interest expressed by clinicians, health services researchers and educators in assessing the perspective of physicians about the processes leading to a decision within specific clinical encounters. This is congruent with the increasing number of randomized trials and systematic reviews examining the efficacy of interventions designed to bring about a change in clinical practice [86]. However, most of these trials assessed a change in health professionals' behaviour without assessing the underlying decision-making process that lead to such behavioural change. This review provides a list of standardized measures of the physician perspective of the clinical decision-making process, an essential step prior to behavioural change. Moreover, most of the included instruments provided some account of their conceptual or theoretical underpinnings. This is important because more attention needs to be given to the combination of different theories that could help us understand professional behaviours [87][88][89][90]. Therefore, this review provides health services researchers and educators with a set of standardized and theory-driven instruments that have the potential to improve the quality of implementation studies and by extension our understanding of health professionals' behaviour changes.
Second, this review provides evidence that health services researchers are beginning to use a dyadic and relationship-centered approach to clinical decision-making [91][92][93]. In other words, health services researchers are moving from studying groups of patients and health professionals separately to studying both simultaneously. For example, five of the six most recently developed instruments had corresponding patient versions [57,58,[60][61][62][63][64][65][66][67][68][69][70][71][77][78][79]81,82]. Moreover, for the authors of two of these instruments, evidence of validity and reliability data was available only for the combined use of the physician's and patient's questionnaires [68,[77][78][79][80][81][82]. This observation suggests that, increasingly, the clinical decision-making process is perceived as not being dissociable from the complex aspects of interdependence occurring between the physician and the patient. Indeed, the patient-physician relationship is an important component of physicians' satisfaction with their job [93]. Physicians' judgements about their experience with individual patients both reflect and shape what takes place during office visits and beyond [84]. This symmetry supports empirically what has previously been described on the basis of personal needs, namely, that both the physician and the patient have the same human needs for connection which can be fulfilled in the clinical encounter [84]. Therefore, future research in the field of clinical decision-making should foster the use of patient and physician versions of a similar instrument. In line with the growing interest for shared decision-making, this may allow for a more comprehensive assessment of the complexity of the clinical decisionmaking process and thus of its dynamic and reciprocal nature [65].
Third, this review highlights the need for further methodological development in studies assessing the perception of physicians of the decision-making process within specific clinical encounters. None of the authors of the included instruments provided data on the responsiveness of their instruments (i.e. the extent to which the instrument measures physician change over time). Also, 'within physician' clustering of multiple data points (i.e. non-independence of data) produced statistical challenges that were dealt with inconsistently by their developers. In one instrument, clustering of multiple data point under each physician was taken into account for the factorial analysis but not for the reliability analyses [84,85].

Participants
Report when study was done, including beginning and ending dates of recruitment.
Report demographic characteristics of the study population (e.g. age, sex, employment, recruitment centers).
Lastly, for the included instruments, the mean number of items ranged from 6 to 37 items (mean = 16.7). It remains a challenge for health service researchers to develop sound measurements for conducting implementation studies that will minimize the burden to participating physicians. In our own experience, and in line with what has been reported in the literature, there appears to be an association between instrument length, defined in this systematic review as the number of items included in an instrument, and physician participation in studies [94]. This is perhaps even more apparent for health professionals' selfadministered questionnaires after a specific clinical encounter. As such, our results provide some valuable insight or benchmarking about the number of items included in the instruments that are currently available for conducting studies on clinical decision-making with physicians.
This review has a number of limitations. Studies reporting the development of instruments are generally not wellindexed in electronic databases [95]. In this review, the search strategies used may not have been optimal even though we consulted with three experienced information specialists. It is possible that some eligible instruments as well as relevant publication regarding the included instruments were not included in this review. Also, clinical decision-making is moving from a unidisciplinary perspective to an interdisciplinary perspective [20]. Therefore, the included instruments might not be representative of ongoing developments in healthcare decision-making. Indeed, recent health services policy documents clearly indicate the need for patient-centered care provided by an interprofessional team [96]. However, in a review on barriers and facilitators to implementing shared decision making in clinical practice as perceived by health professionals, the vast majority of participants (n = 2784) enrolled in the 28 included studies were physicians (89%) [97]. This suggests that more will need to be done to enhance an interprofessional perspective to shared decision making, a process by which a patient and his/her healthcare providers engage in a decision-making process. We firmly believe that the instruments that were identified throughout this review could be further developed using this interprofessional perspective.
Lastly, it is interesting to note that for the eleven included instruments, the mean score of items on the STARD was 12.4 (range: 2 to 18). It is important to emphasize that seven of the included instruments were published before the 2003 STARD criteria. Although, this mean score compared well to the mean scores of items on the STARD that were reported in test accuracy studies in reproductive * For this instrument, only one publication in English was found. This publication reported on the study of physicians that had used the instrument.
Other publications pertaining to this instrument were in German. Table 3: Quality assessment of the studies that reported on the included instruments based on the modified version of STARD * For this instrument, only one publication in English was found. This publication reported on the study of physicians that had used the instrument. Other publications pertaining to this instrument were in German (Continued) medicine: 12.1, future research in this field will need to improve the reporting of the development of instruments that would assess healthcare professional's perspective of the decision-making process

Conclusion
This systematic review provides valuable data on instruments that assess the perception of physicians of the decision-making process within specific clinical encounters. It can be used by educators and health services researchers as a repository of standardized measures of the physician perspective of the clinical decision-making process and we hope of other healthcare providers. It was not our intention to identify the "best" instrument but rather to offer options to the target audience. We believe that based on the context of its intended use, a process of weighting its limitations and strengths and other factors faced by its potential users, most if not all of the identified instruments might play a valuable role in the future. This systematic review also sent an important signal: in the XXI century, the clinical decision-making process might only be adequately assessed by using a dyadic approach. In this regard, some of the identified instruments might be more attractive than others. However, more research is needed to investigate the validation of these instruments. More specifically, for the production of evidence on the validity and reliability data of the instruments, analytical methods that take into account within physician clustering is required. For all the included instruments, the development of corresponding patient versions should be encouraged. The combined use of the patient version with its respective healthcare professional version will help capture the complexity of the clinical decision-making process and thus of its dynamic and reciprocal nature. Only then will a new and more comprehensive understanding of health-related decision-making in the context of specific clinical encounters be possible.