title: Pulmonologists' Reported Use of Guidelines and Shared Decision-making in Evaluation of Pulmonary Nodules: A Qualitative Study.
abstract: BACKGROUND
  Selecting a strategy (surveillance, biopsy, resection) for pulmonary nodule evaluation can be complex given the absence of high-quality data comparing strategies and the important tradeoffs among strategies. Guidelines recommend a three-step approach: (1) assess the likelihood of malignancy, (2) evaluate whether the patient is a candidate for invasive intervention, and (3) elicit the patient's preferences and engage in shared decision-making. We sought to characterize how pulmonologists select a pulmonary nodule evaluation strategy and the extent to which they report following the guideline-recommended approach.
  
  
  METHODS
  We conducted semistructured qualitative interviews with 14 pulmonologists who manage patients with pulmonary nodules at four clinical sites. Transcripts of audiorecorded interviews were analyzed using the principles of grounded theory.
  
  
  RESULTS
  Pulmonologists reported consistently performing steps 1 and 2 but described diverse approaches to step 3 that ranged from always engaging the patient in decision-making to never doing so. Many described incorporating patients' preferences only in particular circumstances, such as when the patient appeared particularly anxious or was aggressive in questioning management options. Indeed, other factors, including convenience, physician preferences, physician anxiety, malpractice concerns, and physician experience, appeared to drive decision-making as much as, if not more than, patient preferences.
  
  
  CONCLUSIONS
  Although pulmonologists appear to routinely personalize pulmonary nodule evaluation strategies based on the individual patient's risk-benefit tradeoffs, they may not consistently take patient preferences into account during the decision-making process. In the absence of high-quality evidence regarding the optimal methods of pulmonary nodule evaluation, physicians should strive to ensure that management decisions are consistent with patients' values.
authors: Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA; Pulmonary Center, Department of Medicine, Oregon Health and Science University, Portland, OR. Electronic address: rwiener@bu.edu.
authors: Renda Soylemez
authors: RS
authors: Wiener
authors: Health Services Research and Development, Department of Medicine, Oregon Health and Science University, Portland, OR; Section of Pulmonary and Critical Care Medicine, VA Portland Health Care System, Portland, OR; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR.
authors: Christopher G
authors: CG
authors: Slatore
authors: Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA.
authors: Chris
authors: C
authors: Gillespie
authors: Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA; Department of Health Policy and Management, Boston University School of Public Health, Boston, MA.
authors: Jack A
authors: JA
authors: Clark
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D003657:Decision Making; D019468:Disease Management; D019983:Guideline Adherence; D006801:Humans; D008175:Lung Neoplasms / Q000473:pathology / Q000523:psychology; D008875:Middle Aged; D055613:Multiple Pulmonary Nodules / Q000175:diagnosis / Q000523:psychology / Q000628:therapy; D057240:Patient Preference; D010817:Physician-Patient Relations; D017410:Practice Guidelines as Topic; D011336:Probability; D015272:Pulmonary Medicine / Q000379:methods; D036301:Qualitative Research; D018570:Risk Assessment / Q000379:methods*; D003074:Solitary Pulmonary Nodule / Q000175:diagnosis / Q000523:psychology / Q000628:therapy