Patient and physician perspectives on treatments for low-risk prostate cancer: a qualitative study.

BACKGROUND: Patients diagnosed with low-risk prostate cancer (PCa) are confronted with a difficult decision regarding whether to undergo definitive treatment or to pursue an active surveillance protocol. This is potentially further complicated by the possibility that patients and physicians may place different value on factors that influence this decision. We conducted a qualitative investigation to better understand patient and physician perceptions of factors influencing treatment decisions for low-risk PCa. METHODS: Semi-structured interviews were conducted among 43 racially and ethnically diverse patients diagnosed with low-risk PCa, who were identified through a population-based cancer registry, and 15 physicians who were selected to represent a variety of practice settings in the Greater San Francisco Bay Area. RESULTS: Patients and physicians both described several key individual (e.g., clinical) and interpersonal (e.g., healthcare communications) factors as important for treatment decision-making. Overall, physicians' perceptions largely mirrored patients' perceptions. First, we observed differences in treatment preferences by age and stage of life. At older ages, there was a preference for less invasive options. However, at younger ages, we found varying opinions among both patients and physicians. Second, patients and physicians both described concerns about side effects including physical functioning and non-physical considerations. Third, we observed differences in expectations and the level of difficulty for clinical conversations based on information needs and resources between patients and physicians. Finally, we discovered that patients and physicians perceived patients' prior knowledge and the support of family/friends as facilitators of clinical conversations. CONCLUSIONS: Our study suggests that the gap between patient and physician perceptions on the influence of clinical and communication factors on treatment decision-making is not large. The consensus we observed points to the importance of developing relevant clinical communication roadmaps as well as high quality and accessible patient education materials.

Decision aids for localized prostate cancer in diverse minority men: Primary outcome results from a multicenter cancer care delivery trial (Alliance A191402CD).

BACKGROUND: Decision aids (DAs) can improve knowledge for prostate cancer treatment. However, the relative effects of DAs delivered within the clinical encounter and in more diverse patient populations are unknown. A multicenter cluster randomized controlled trial with a 2×2 factorial design was performed to test the effectiveness of within-visit and previsit DAs for localized prostate cancer, and minority men were oversampled. METHODS: The interventions were delivered in urology practices affiliated with the NCI Community Oncology Research Program Alliance Research Base. The primary outcome was prostate cancer knowledge (percent correct on a 12-item measure) assessed immediately after a urology consultation. RESULTS: Four sites administered the previsit DA (39 patients), 4 sites administered the within-visit DA (44 patients), 3 sites administered both previsit and within-visit DAs (25 patients), and 4 sites provided usual care (50 patients). The median percent correct in prostate cancer knowledge, based on the postvisit knowledge assessment after the intervention delivery, was as follows: 75% for the pre+within-visit DA study arm, 67% for the previsit DA only arm, 58% for the within-visit DA only arm, and 58% for the usual-care arm. Neither the previsit DA nor the within-visit DA had a significant impact on patient knowledge of prostate cancer treatments at the prespecified 2.5% significance level (P = .132 and P = .977, respectively). CONCLUSIONS: DAs for localized prostate cancer treatment provided at 2 different points in the care continuum in a trial that oversampled minority men did not confer measurable gains in prostate cancer knowledge.

Colorectal Cancer Screening During the COVID-19 Pandemic.

Shared decision-making (SDM) can help patients make good decisions about preventive health interventions such as cancer screening. We illustrate the use of SDM in the case of a 53-year-old man who had a new patient visit with a primary care physician and had never been screened for colorectal cancer (CRC). The patient had recently recovered from a serious COVID-19 infection requiring weeks of mechanical ventilation. When the primary care physician initially offered a screening colonoscopy, the man expressed great reluctance to return to the hospital for the exam. The PCP then offered a stool test, which could be completed at home, but emphasized that if it were positive, a colonoscopy would be required. He agreed to complete the stool test, and unfortunately, it was positive. He then agreed to undergo colonoscopy, which uncovered a large rectal cancer. The carcinoma had invaded the mesorectal fat but there were no metastases. After undergoing neoadjuvant chemotherapy followed by a low anterior resection of the tumor, he has no evidence of recurrence so far. Many clinicians favor colonoscopy for CRC screening, but evidence suggests that patients who are offered more than one reasonable option are more likely to undergo screening. If screening had been delayed in this patient until he was willing to accept a screening colonoscopy, there was the potential the cancer may have been more advanced when diagnosed, with a worse outcome. Shared decision-making was a key approach to understanding the patient's feelings related to this screening decision and making a decision consistent with his preferences.

Women, Younger Clinicians', and Caregivers' Experiences of Burnout and Well-being During COVID-19 in a US Healthcare System.

BACKGROUND: The COVID-19 pandemic brought rapid changes to the work and personal lives of clinicians. OBJECTIVE: To assess clinician burnout and well-being during the COVID-19 pandemic and guide healthcare system improvement efforts. DESIGN: A survey asking about clinician burnout, well-being, and work experiences. PARTICIPANTS: Surveys distributed to 8141 clinicians from June to August 2020 in 9 medical groups and 17 hospitals at Sutter Health, a large healthcare system in Northern California. MAIN MEASURES: Burnout was the primary outcome, and other indicators of well-being and work experience were also measured. Descriptive statistics and multivariate logistic regression analyses were performed. All statistical inferences were based on weighted estimates adjusting for response bias. KEY RESULTS: A total of 3176 clinicians (39.0%) responded to the survey. Weighted results showed 29.2% reported burnout, and burnout was more common among women than among men (39.0% vs. 22.7%, p<0.01). In multivariate models, being a woman was associated with increased odds of reporting burnout (OR=2.19, 95% CI: 1.51-3.17) and being 55+ years old with lower odds (OR=0.54, 95% CI: 0.34-0.87). More women than men reported that childcare/caregiving was impacting work (32.9% vs. 19.0%, p<0.01). Even after controlling for age and gender, clinicians who reported childcare/caregiving responsibilities impacted their work had substantially higher odds of reporting burnout (OR=2.19, 95% CI: 1.54-3.11). Other factors associated with higher burnout included worrying about safety at work, being given additional work tasks, concern about losing one's job, and working in emergency medicine or radiology. Protective factors included believing one's concerns will be acted upon and feeling highly valued. CONCLUSIONS: This large survey found the pandemic disproportionally impacted women, younger clinicians, and those whose caregiving responsibilities impacted their work. These results highlight the need for a holistic and targeted strategy for improving clinician well-being that addresses the needs of women, younger clinicians, and those with caregiving responsibilities.

The Relationship Between Primary Care Physician Burnout and Patient-Reported Care Experiences: a Cross-sectional Study.

BACKGROUND: Primary care physician (PCP) burnout is prevalent and on the rise. Physician burnout may negatively affect patient experience of care. OBJECTIVE: To identify the direct impact of PCP burnout on patient experience in various domains of care. DESIGN: A cross-sectional observational study using physician well-being (PWB) surveys collected in 2016-2017, linked to responses from patient experience of care surveys. Patient demographics and practice characteristics were derived from the electronic health record. Linked data were analyzed at the physician level. SETTING: A large non-profit multi-specialty ambulatory healthcare organization in northern California. PARTICIPANTS: A total of 244 physicians practicing internal medicine or family medicine who responded to the PWB survey (response rate 72%), and 30,701 completed experience surveys from patients seeing these physicians. MEASUREMENTS: Burnout was measured with a validated single-item question with a 5-point scale ranging from (1) enjoy work to (5) completely burned out and seeking help. Patient experience of patient-provider communication, access, and overall rating of provider was measured with Clinician & Group Consumer Assessment of Healthcare Providers & Systems (CG-CAHPS) survey. Patient experience scores (0-100 scale) were adjusted for age, gender, race/ethnicity, and English proficiency. RESULTS: Physician burnout had a negative impact on patient-reported experience of patient-provider communication but not on access or overall rating of providers. A one-level increase in burnout was associated with 0.43 decrease in adjusted patient-provider communication experience score (P < 0.01). LIMITATIONS: Data came from a single large healthcare organization. Patterns may differ for small- and mid-sized practices. CONCLUSION: Physician burnout adversely affects patient-provider communication in primary care visits. Efforts to improve physician work environments could have a meaningful positive impact on patient experience as well as physician well-being.

Frontline Perspectives on Physician Burnout and Strategies to Improve Well-Being: Interviews with Physicians and Health System Leaders.

BACKGROUND: Nationally over 50% of physicians report symptoms of burnout. OBJECTIVE: To understand the perspectives of health system leaders and frontline physicians on contributors to physician burnout and strategies to improve well-being. DESIGN: We conducted in-depth interviews with health system leaders and frontline physicians at a large, predominantly fee-for-service, multispecialty group practice with approximately 1300 physicians. PARTICIPANTS: The 17 participants included 15 physicians, (12 Internal Medicine and Family Medicine physicians and 3 from other specialties), 11 individuals in leadership roles, and 11 women. APPROACH: Interviews included a review of factors associated with burnout at the organization, asking participants which factors they believed contributed to burnout, questions about experiences of burnout, and what specific changes would improve well-being. KEY RESULTS: All 17 participants agreed that organizational factors were key contributors to burnout, while only 9 mentioned the salience of individual factors: "It does not matter how resilient or positive you are, the work environment, especially in primary care will eventually be a problem." An increasing workload associated with the electronic health record (EHR) and a culture focused on productivity were cited as contributing to burnout, especially among physicians in Internal Medicine and Family Medicine (primary care) departments. Physicians in primary care, women, and leaders described multiple barriers to well-being. Participants described responding to increased workloads by reducing clinical work hours. Participants suggested reducing and compensating EHR work, expanding care teams/support staff, reducing use of metrics, providing more support to leaders, changing the business model, and increasing positivity and collegiality, as essential to improving well-being. CONCLUSION: Interviews reveal a variety of interacting factors contributing to physician burnout. Reducing clinical work hours has become a coping strategy. Changes recommended to improve physician well-being include increasing support staff, reducing EHR workload, changing revenue generation and compensation approaches, and shifting organizational culture to place more value on physician wellness.

Patient-Centric Scheduling With the Implementation of Health Information Technology to Improve the Patient Experience and Access to Care: Retrospective Case-Control Analysis.

BACKGROUND: Cancellations and rescheduling of doctor's appointments are common. An automated rescheduling system has the potential to facilitate the rescheduling process so that newly opened slots are promptly filled by patients who need and can take the slot. Building on an existing online patient portal, a large health care system adopted an automated rescheduling system, Fast Pass, that sends out an earlier appointment offer to patients via email or SMS text messaging and allows patients to reschedule their appointment through the online portal. OBJECTIVE: We examined the uptake of Fast Pass at its early stage of implementation. We assessed program features and patient and visit characteristics associated with higher levels of Fast Pass utilization and the association between Fast Pass use and no-show and cancellation rates. METHODS: This study was a retrospective analysis of Fast Pass offers sent between July and December 2018. Multivariable logistic regression was used to assess the independent contribution of program, patient, and visit characteristics on the likelihood of accepting an offer. We then assessed the appointment outcome (completion, cancellation, or no-show) of Fast Pass offered appointments compared to appointments with the same patient and visit characteristics, but without an offer. RESULTS: Of 177,311 Fast Pass offers sent, 14,717 (8.3%) were accepted. Overall, there was a 1.3 percentage point (38%) reduction in no-show rates among Fast Pass accepted appointments compared to other appointments with matching characteristics (P<.001). The offers were more likely to be accepted if they were sent in the evening (versus early morning), the first (versus repeated) offer for the same appointment, for a slot 1-31 days ahead (versus same-day), for later in a day (versus before 10am), for a primary care (versus specialty) visit, sent via SMS text messaging (versus email only), for an appointment made through the online patient portal (versus via phone call or in-person), or for younger adults aged 18-49 years (versus those aged 65 years or older; all at P<.001). Factors negatively associated with offer acceptance were a higher number of comorbidities (P=.02) and visits scheduled for chronic conditions (versus acute conditions only; P=.002). CONCLUSIONS: An automated rescheduling system can improve patients' access by reducing wait times for an appointment, with an added benefit of reducing no-shows by serving as a reminder of an upcoming appointment. Future modifications, such as increasing the adoption of SMS text messaging offers and targeting older adults or patients with complex conditions, may make the system more patient-centered and help promote wider utilization.

Development of a patient decision aid for the management of superficial basal cell carcinoma (BCC) in adults with a limited life expectancy.

BACKGROUND: Basal cell carcinoma (BCC) is a slow-growing, rarely lethal skin cancer that affects people 65 years or older. A range of treatment options exist for BCC, but there is little evidence available to guide patients and providers in selecting the best treatment options. OBJECTIVES: This study outlines the development of a patient decision aid (PDA) for low-risk BCC that can be used by patients and providers to assist in shared decision-making. METHODS: In accordance with the International Patient Decision Aids Standards (IPDAS) Collaboration framework, feedback from focus groups and semi-structured interviews with patients and providers, an initial prototype of the PDA was developed. This was tested using cognitive interviews and iteratively updated. RESULTS: We created eighteen different iterations using feedback from 24 patients and 34 providers. The key issues identified included: 1) Addressing fear of cancer; 2) Communicating risk and uncertainty; 3) Values clarification; and 4) Time lag to benefit. LIMITATIONS: The PDA does not include all possible treatment options and is currently paper based. CONCLUSIONS: Our PDA has been specifically adapted and designed to support patients with a limited life expectancy in making decisions about their low risk BCC together with their doctors.

Perioperative Complications Stratified by Body Mass Index for the Direct Anterior Approach to Total Hip Arthroplasty.

BACKGROUND: Previous studies have addressed the increased risk of perioperative complications in the obese and morbidly obese populations undergoing total hip arthroplasty. Over the last 15 years, the direct anterior approach has increased in popularity. The purpose of this study is to compare the 90-day perioperative complication rate of total hip arthroplasty performed through the direct anterior approach stratified by body mass index (BMI). METHODS: Perioperative complications both intraoperative and up to 90 days postoperative were identified in a case series of 1808 primary total hip arthroplasties performed through a direct anterior approach. The patients were stratified according to BMI. Demographics of age, side, sex, and American Society of Anesthesiologists score were recorded. Medical and surgical complications including National Surgical Quality Improvement Program complications, length of stay, reoperation rate, readmission rate, and length of operation were recorded. Bivariate analysis and analysis of variance were performed. RESULTS: Morbidly obese patients (BMI > 40) demonstrated increased American Society of Anesthesiologists scores, increased surgical times with statistically significant increase in number of patients with surgical complications, National Surgical Quality Improvement Program complications, deep infection, and wound breakdown. Grading the severity of complications also demonstrated the morbidly obese had a higher risk of experiencing more severe complications. Underweight patients (BMI < 18.5) demonstrated a statistically significant readmission rate. CONCLUSION: In stratifying patients undergoing the direct anterior approach for total hip arthroplasty by BMI, a greater rate of surgical complications both in number and in severity occurs with the morbidly obese undergoing total hip arthroplasty through a direct anterior approach.

Effectiveness of Shared Decision-making for Diabetes Prevention: 12-Month Results from the Prediabetes Informed Decision and Education (PRIDE) Trial.

IMPORTANCE: Intensive lifestyle change (e.g., the Diabetes Prevention Program) and metformin reduce type 2 diabetes risk among patients with prediabetes. However, real-world uptake remains low. Shared decision-making (SDM) may increase awareness and help patients select and follow through with informed options for diabetes prevention that are aligned with their preferences. OBJECTIVE: To test the effectiveness of a prediabetes SDM intervention. DESIGN: Cluster randomized controlled trial. SETTING: Twenty primary care clinics within a large regional health system. PARTICIPANTS: Overweight/obese adults with prediabetes (BMI ≥ 24 kg/m2 and HbA1c 5.7-6.4%) were enrolled from 10 SDM intervention clinics. Propensity score matching was used to identify control patients from 10 usual care clinics. INTERVENTION: Intervention clinic patients were invited to participate in a face-to-face SDM visit with a pharmacist who used a decision aid (DA) to describe prediabetes and four possible options for diabetes prevention: DPP, DPP ± metformin, metformin only, or usual care. MAIN OUTCOMES AND MEASURES: Primary endpoint was uptake of DPP (≥ 9 sessions), metformin, or both strategies at 4 months. Secondary endpoint was weight change (lbs.) at 12 months. RESULTS: Uptake of DPP and/or metformin was higher among SDM participants (n = 351) than controls receiving usual care (n = 1028; 38% vs. 2%, p < .001). At 12-month follow-up, adjusted weight loss (lbs.) was greater among SDM participants than controls (- 5.3 vs. - 0.2, p < .001). LIMITATIONS: Absence of DPP supplier participation data for matched patients in usual care clinics. CONCLUSIONS AND RELEVANCE: A prediabetes SDM intervention led by pharmacists increased patient engagement in evidence-based options for diabetes prevention and was associated with significantly greater uptake of DPP and/or metformin at 4 months and weight loss at 12 months. Prediabetes SDM may be a promising approach to enhance prevention efforts among patients at increased risk. TRIAL REGISTRATION: This study was registered at clinicaltrails.gov (NCT02384109)).

Actions and processes that patients, family members, and physicians associate with patient- and family-centered care.

BACKGROUND: Patient- and family-centered care (PFCC) is increasingly linked to improved communication, care quality, and patient decision making. However, in order to consistently implement and study PFCC, health care systems and researchers need a solid evidentiary base. Most current definitions and models of PFCC are broad and conceptual, and difficult to translate into measurable behaviors and actions. This paper provides a brief overview of all actions that focus group respondents associated with PFCC in ambulatory (outpatient) care settings and then explores actions associated with the concept of "dignity and respect" in greater detail. METHODS: We conducted nine focus groups with patients, family members, and physicians in three metropolitan regions across the United States. Group discussions were transcribed and analyzed using a thematic analysis approach. RESULTS: We identified 14 domains and 47 specific actions that patients, family members, and physicians associate with PFCC. In addition to providing a detailed matrix of these domains and actions, this paper details the actions associated with the "dignity and respect" concept. Key domains identified under "dignity and respect" include: 1) building relationships, 2) providing individualized care, and 3) respecting patients' time. Within these domains we identified specific actions that break down these abstract ideas into explicit and measurable units such as taking time, listening, including family, and minimizing wait times. We identified 9, 6, and 3 specific actions associated, respectively, with building relationships, providing individualized care, and respecting patients' time. CONCLUSIONS: Our work fills a critical gap in our ability to understand and measure PFCC in ambulatory care settings by breaking down abstract concepts about PFCC into specific measurable actions. Our findings can be used to support research on how PFCC affects clinical outcomes and develop innovative tools and policies to support PFCC.

Isolated Greater Trochanteric Fracture and the Direct Anterior Approach Using a Fracture Table.

BACKGROUND: To identify the incidence, contributing factors, and outcomes of perioperative greater trochanter fractures associated with the direct anterior approach. METHODS: This is a retrospective analyses of 1401 primary THAs. Age, side, height, weight, body mass index, preoperative ambulatory status, discharge status, and hospital length of stay were identified. Radiographs were evaluated for femoral neck angle, femoral neck cut ratio (FNCR), and DORR ratio. Bivariate and logistic regression analyses were performed. RESULTS: Thirty-one hips sustained isolated greater trochanter fractures (2.2%). Multivariate analyses identified worse preoperative ambulatory status, diagnosis of slipped capital femoral epiphysis or rheumatoid arthritis, lower FNCR and greater DORR ratio as statistically significant predictors for fracture. Four intraoperative fractures underwent fixation. All postoperative fractures were treated nonoperatively. Thirty fractures healed with 1 nonunion. CONCLUSION: Worse preoperative ambulatory status, diagnosis of slipped capital femoral epiphysis or rheumatoid arthritis, greater DORR ratio, and lower FNCR were associated with increased risk of fracture. Hips with fractures had longer length of stay. Nonoperative treatment was uniformly successful.

A Clinician's Guide to Privacy and Communication in the ICU.

OBJECTIVE: To review the legal issues concerning family members' access to information when patients are in the ICU. DATA SOURCES: U.S. Code, U.S. Code of Federal Regulations, and state legislative codes. DATA EXTRACTION: Relevant legal statutes and regulations were identified and reviewed by the two attorney authors (L. F., M. A. V.). STUDY SELECTION: Not applicable. DATA SYNTHESIS: Review by all coauthors. CONCLUSIONS: The Health Insurance Portability and Accountability Act and related laws should not be viewed as barriers to clinicians sharing information with ICU patients and their loved ones. Generally, under Health Insurance Portability and Accountability Act, personal representatives have the same authority to receive information that patients would otherwise have. Persons involved in the patient's care also may be given information relevant to the episode of care unless the patient objects. ICUs should develop policies for handling the issues we identify about such information sharing, including policies for responding to telephone inquiries and methods for giving patients the opportunity to object to sharing information with individuals involved in their care. ICU clinicians also should be knowledgeable of their state's laws about how to identify patients' personal representatives and the authority of those representatives. Finally, ICU clinicians should be aware of any special restrictions their state places on medical information. In aggregate, these strategies should help ICU managers and clinicians facilitate robust communication with patients and their loved ones.

Navicular Stress Fracture Outcomes in Athletes: Analysis of 62 Injuries.

The optimal treatment modalities for navicular stress fractures in athletes is currently unknown for this season-ending injury. The present study evaluated factors that might be significant and affect healing outcomes, specifically focusing on the return to activity (RTA) time and a decreased desired activity (DDA) after treatment in athletes. Such considerations included previous navicular stress fractures, patient demographic data and type of sport, and initiation time of treatment. The data from 59 patients with 62 fractures were prospectively analyzed from May 2005 through July 2016. The results showed a significant correlation between a previous navicular stress fracture and decreased desired activity. The average duration of symptoms before receiving definitive treatment was 8.8 months. Computed tomography as the initial imaging modality correlated positively with a correct diagnosis (1.00). In contrast, magnetic resonance imaging, when used initially, was only 71% accurate. Runners constituted most of the cohort at 38 (61.3%). Ten other athletes were involved in jumping sports. Of the 62 injuries, 21 (33.9%) were in elite or professional athletes, all of whom were able to RTA, with 1 patient, a 38-year-old world record holding runner, having a DDA. Seven refractures (11.2%) occurred an average >5 years after the initial injury, predominantly in those aged <21 years, none with previous surgery. Eight patients (12.9%) developed postinjury arthrosis, including 1 with DDA. Patients who underwent open reduction and internal fixation had a RTA of 4.56 months compared with those who had undergone nonoperative treatment, who had an average RTA of 3.97 months. Seven patients (11.2%) underwent screw removal and required a longer RTA. Overall, of the 62 injuries, the patients with 57 of the injuries (91.9%) were able to RTA at their preinjury level.

Who and when should we screen for prostate cancer? Interviews with key opinion leaders.

Prostate cancer screening using prostate-specific antigen (PSA) is highly controversial. In this Q & A, Guest Editors for BMC Medicine's 'Spotlight on Prostate Cancer' article collection, Sigrid Carlsson and Andrew Vickers, invite some of the world's key opinion leaders to discuss who, and when, to screen for prostate cancer. In response to the points of view from the invited experts, the Guest Editors summarize the experts' views and give their own personal opinions on PSA screening.

A Randomized Controlled Effectiveness Trial for PSA Screening Decision Support Interventions in Two Primary Care Settings.

BACKGROUND: Decision support interventions (DESIs) provide a mechanism to translate comparative effectiveness research results into clinical care so that patients are able to make informed decisions. Patient decision support interventions for prostate-specific antigen (PSA) have been shown to promote informed decision making and reduce PSA testing in efficacy trials, but their impact in real world settings is not clear. OBJECTIVE: We performed an effectiveness trial of PSA decision support interventions in primary care. DESIGN: A randomized controlled trial of three distribution strategies was compared to a control. PARTICIPANTS: Participants included 2,550 men eligible for PSA testing (76.6 % of the eligible population) and 2001 survey respondents (60.1 % survey response rate). INTERVENTIONS: The intervention groups were: 1) mailed the DESI in DVD format, 2) offered a shared medical appointment (SMA) to view the DESI with other men and discuss, and 3) both options. MAIN MEASURES: We measured PSA testing identified via electronic medical record at 12 months and DESI use by self-report 4 months after the intervention mailing. KEY RESULTS: We found no differences in PSA testing across the three distribution strategies over a year-long follow-up period: 21 %, 24 %, 22 % in the DESI, SMA, and combined group respectively, compared to 21 % in the control group (p = 0.51). Self-reported DESI use was low across all strategies at 4 months: 16 % in the mailed DESI group, 6 % in the SMA group, and 15 % in the combined group (p = < 0.0001). CONCLUSIONS: Mailing PSA decision support interventions or inviting men to shared medical appointments unrelated to a primary care office visit do not appear to promote informed decision making, or change PSA testing behavior.

Physicians' perceptions of shared decision-making behaviours: a qualitative study demonstrating the continued chasm between aspirations and clinical practice.

BACKGROUND: Shared Decision Making (SDM) is a process of engaging patients in health decisions that involve multiple medically appropriate treatment options. Despite growing public and policy support for patient engagement in health decisions, SDM is not widely practiced in clinical settings. OBJECTIVE: The purpose of our study was to explore clinicians' attitudes, beliefs and perceived social norms about engaging in SDM behaviours. DESIGN: Semi-structured qualitative interviews were conducted with physicians in five practice areas. SETTING AND PARTICIPANTS: This study was conducted at an academic medical centre in St. Louis, MO. The final sample included 20 physicians: five surgeons, five OB/GYNs, four medical oncologists, five internists and one emergency medicine physician. RESULTS: Clinicians described a number of beliefs and cultural- and system-level obstacles to the widespread implementation of SDM, such as how to engage in discussions of cost, uncertainty and clinical equipoise and how to engage patients across various socioeconomic backgrounds. CONCLUSION: Although a large number of participants expressed general support for incorporating SDM into practice, most held fundamentally inconsistent beliefs about practicing specific SDM behaviours. More extensive training of physicians at all levels (pre- and post-licensure) can help increase clinicians' confidence in SDM skills. Developing methods of integrating SDM into the institutional framework of hospitals and training programmes could also increase clinicians' motivation to practice SDM and work to change the culture of medicine such that SDM behaviours are supported.