Exploring Shared Decision-Making | 87 3 Lastly, a longer consultation time and a higher patient OPTION-score were found to positively increase surgeons’ OPTION-score. Longer consultation time and an active patient during SDM are two known correlates33, 38, 39. However, further implementation and improvement of SDM into HNC decision-making does not necessarily have to lead to prolonged duration of the consultation64, 65. Although, consultation time may initially increase while healthcare providers are still in training and learning to apply SDM in their consultations, the duration of the consultations may decrease once they have acquired adequate SDM skills66. While we hypothesized that being an older patient and lower literacy would relate to a lower OPTION-score, as suggested in qualitative research67, we found no significant correlations for any patient and tumor characteristic. Limitations We acknowledge that this study has some limitations. First, due to the exploratory nature of the study, only five surgeons from one hospital were included. Nevertheless, an attempt was made to assemble a reality-based group, with different ages and only one female surgeon (out of 2 employed). Multivariate analysis was not possible due to limited power, indicating the need for more research on SDM in HN oncology. Second, consultations were only audio recorded, whereas videos could have provided more insight into the communication process through nonverbal communication68. Third, surgeons’ effort to apply SDM may have been stimulated by our study, as they were aware of being audiotaped. However, effect of the presence of an audio recorder during consultation has been reported to be negligible69. Fourth, the proposed treatment modality may have influenced the duration of consultations. For instance, HN may spend less time explaining radiotherapy treatment plans in detail compared to surgical procedures. This suggests that rather than the consultation length itself being directly related to SDM, the type of treatment proposed might influence the length of the consultation. Fifth, the SDM-Q9 and SDM-Doc questionnaires seem to be overly generic instruments for measuring perceived SDM levels. They lack detailed elaboration of each item, which is necessary to fully appreciate the quality of SDM. Lastly, although the OPTIONmcc+ reflects the three-talk model of SDM, it cannot be directly compared with the SDM-Q-9 and SDM-Q-DOC questionnaires due to the difference in items. For example, OPTION items 1 ‘goal talk’, 3 ‘team talk’, 6 ‘integrative decision talk’, and 7 ‘evaluation talk’ do not appear to be exactly included in the SDM-Q questionnaires. No statistical correlation exists between all items of both measures that assess the same part of the SDM process70. Measuring SDM thus so far remains challenging, making the need for future research using measures with the exact same items that are comparable even more profound.
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