Patient Education and Counseling 129 (2024) 108410

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Patient Education and Counseling

journal homepage: www.journals.elsevier.com/patient-education-and-counseling

Patient experience and satisfaction with shared decision-making: A

cross-sectional study among outpatients
Cindy Yue Tian a,b , Eliza Lai-Yi Wong a,b,* , Hong Qiu a,b , Shi Zhao c , Kailu Wang a,b,
Annie Wai-Ling Cheung a,b , Eng-Kiong Yeoh a,b
a
JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
b
Centre for Health Systems and Policy Research, JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China
c
School of Public Health, Tianjin Medical University, Tianjin, China

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: This study aimed to investigate how doctor-patient communication, trust in doctors impacted patients’
Patient experience experience and satisfaction in shared decision-making (SDM).
Patient satisfaction Methods: This study is based on the data from a cross-sectional survey (n = 12,401) conducted in 27 public
Shared decision-making
specialist outpatient clinics in Hong Kong.
Outpatients
Results: The multivariable regression models revealed that doctors’ better communication skills were associated
with lower decision-making involvement (odd ratio, 0.75 [95 % CI, 0.88–0.94], P < .001) but higher satisfaction
with involvement (odd ratio, 6.88 [95 % CI, 5.99–7.93], P < .001). Similarly, longer consultation durations were
associated with reduced involvement in decision-making (odd ratio, 0.71 [95 % CI, 0.66–0.73], P < .001) but
increased satisfaction with involvement (odd ratio, 1.91 [95 % CI, 1.80–2.04], P < .001). Trust in doctors
significantly mediated these associations, except for the association between consultation duration and patients’
satisfaction with decision-making involvement.
Conclusion: Doctors’ better communication skills and longer consultations might not necessarily increase patient
involvement in SDM but correlated with increased satisfaction with involvement. Trust in doctors emerged as a
mediator for participation and satisfaction in decision-making.
Practice implications: Clinics should consider patients’ preferences and capabilities when tailoring communication
strategies about decision-making and optimizing patient satisfaction.

1. Introduction problematic, with studies showing limited patient participation in

decision-making [6–11]. For example, one recent systematic review
In healthcare, there has been a shift from a more paternalistic care suggested that over one-third of cancer patients perceived being
model in which healthcare providers tell patients what they should do, passively engaged in decision-making on their treatment (i.e., a doctor
to a collaborative one in which healthcare providers engage in joint made the final decision but considered the patient’s opinion or left all
deliberations with patients. In this context, shared decision-making decisions to the doctor) [12].
(SDM) is widely recognized as a comprehensive approach for Patient preference for involvement in SDM varies among individuals
achieving such collaborative patient-centered care [1]. SDM is a process because of different sociodemographic characteristics, cultural norms,
in which healthcare providers and patients work together to make de­ and disease severity [12–15]. Some patients may wish to be active in
cisions about the patient’s treatment and care. It involves the exchange medical decision-making, while others may prefer to delegate decisions
of information, mutual discussion, and consideration of both medical to physicians as they may perceive their involvement in a healthcare
evidence and the patient’s preferences, values and circumstances [2]. decision as being a substantial burden on them. A mismatch between a
This approach leads to more informed choices, better treatment patient’s preferred and actual involvement in the decision-making pro­
compliance and improved health outcomes [3–5]. However, the cess might lead to reduced treatment compliance and satisfaction with
implementation of SDM in routine medical care remains the overall healthcare system [8,16]. Such dis-concordance or

* Corresponding author at: JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China.
E-mail address: lywong@cuhk.edu.hk (E.L.-Y. Wong).

https://doi.org/10.1016/j.pec.2024.108410
Received 24 April 2024; Received in revised form 9 August 2024; Accepted 24 August 2024
Available online 28 August 2024
0738-3991/© 2024 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
C.Y. Tian et al. Patient Education and Counseling 129 (2024) 108410

dissatisfaction with experienced participation has been investigated in our previous experiences, the phone interview mode of the survey would
patients with cancer [12], heart diseases [17], psychiatric disorders be one of the most effective ways to contact our target study groups in
[18], and stroke [19]. More attention to patient-preferred roles in SDM Hong Kong. In addition, it is physically and economically feasible to
is needed, however, particularly considering that prior research on this conduct the interview with illiterate or elderly patients as compared
topic has been limited by small sample sizes and disease-specific focuses. with using the self-administration-of-survey instrument mode. There­
Doctor-patient communication [20–22] is an important facilitator of fore, the survey was conducted using telephone interviews to recruit a
patients’ participation in SDM. Effective communication makes pa­ representative sample of the SOPC patients within the project timeline in
tients feel comfortable and empowered. In outpatient clinics, the survey. Ethical approval was obtained from the Clinical Research
where doctors are the primary healthcare providers, good Ethics Committee of The Chinese University of Hong Kong.
communication is essential but often challenging due to staff Patients eligible for the survey were Hong Kong residents aged
shortages and high patient loads [20,21]. In Hong Kong, exemplifying 18 or older, reachable within two weeks of SOPC attendance, and
these challenges, the annual specialist outpatient service at public hos­ able to communicate in Cantonese, English, or Mandarin. Exclu­
pitals has reached eight million with about 900,000 new cases every sions included those who underwent day surgery, had mental
year and waiting time for new cases that spans years [23,24]. This raise a disabilities, were admitted as inpatients post-SOPC, or attended
critical question: how does doctor-patient communication affect SDM in SOPCs for pediatrics, hospice, psychiatry, dental, anesthesiology,
local daily clinical practice? Furthermore, according to the Health Belief pathology, or multi-specialty outpatient/nurse clinics. Patients
Model [25], when patients trust their doctors due to effective commu­ with mental disabilities and those requiring psychiatric treatment
nication, they may be more likely to believe in the benefits of SDM. This were excluded due to the need for different approaches, such as
belief can then motivate them to actively engage in the face-to-face interviews and tailored questionnaires. Similarly, pa­
decision-making process. Previous research among inpatients with tients attending SOPCs for the excluded specialties were not
general chronic medical conditions or specific diseases revealed a low involved due to their different care pathways.
level of trust in the doctor linked to reduced involvement in SDM To recruit participants, initial verbal consent to join the survey was
[26–29]. Notably, short consultation time at the public outpatient clinic obtained from the target study patients via telephone with the assistance
leads to a smaller window period and greater challenges for patient of the HA. Respondents were informed about their rights to refuse or
communication and building trust between doctor and patient. Given withdraw, the study’s purpose, and research procedures before the
that, studies exploring how doctor-patient communication and trust in interview. They then had the opportunity to consent after understanding
doctors affect patient involvement in decision-making in outpatients, the facts and possible risks. Surrogate respondents were not allowed. A
remain limited. Understanding the interplay among communication, total of ten interviewers conducted the telephone survey. All in­
trust, and SDM is essential for optimizing the practice of SDM and terviewers were well-trained following a standard protocol and
promoting patient-centred care in outpatient services. given a field operation manual. A team supervisor coordinated and
There is limited discussion on patient experience and their satisfac­ monitored all fieldwork and follow-up calls. A stratified random
tion of SDM in Hong Kong. Previous local studies mainly focused on sampling was employed to ensure the representativeness of the
specific healthcare settings or patient groups, such as surgical in­ target population. Around 200–590 responses were estimated for
terventions [30], antenatal genetic screening [31], end-of-life care [32], each SOPC according to their patient attendance volume with the
and old adults [33]. More comprehensive discussions on SDM across assumption of 50 % of respondents with a positive experience at a
a broader range of contexts are needed. With no formal policy plan 95 % confidence level and ± 4.0 % of prevision level of response.
regarding SDM in Hong Kong, insights from a region-wide outpa­ Eligible SOPC attendees were randomly selected on a weekly to
tient experience survey can enhance SDM practices by providing enhance representativeness over the study period.
crucial evidence on patients’ experiences with SDM and the factors
influencing them. Therefore, this study aimed to employ a patient 2.2. Study outcomes
experience survey to investigate the associations between doctor-patient
communication (including doctor communication skills and patient In this study, we evaluated patient experience in SDM by valuing
consultation duration) and patients’ experience and satisfaction in SDM, their perceived level of involvement, similar to approaches used in
and thus determine if patients’ trust in doctors plays a mediating role in previous research [36–38]. To do this, we used a single question asking
these associations among specialist outpatients. Specifically, the their overall perception of involvement in decisions about medical care
research questions are: 1) What is the association between and treatment, categorized into involved (“yes, definitely” and “yes, to
doctor-patient communication and patients’ perceived involve­ some extent”) and not involved (“no”). Satisfaction with the perceived
ment in SDM? 2) What is the association between doctor-patient involvement was defined as follows: satisfied (“good enough”) and
communication and patients’ satisfaction with their involvement dissatisfied (want “more” or “less” involvement or “did not want to be
in SDM? 3) Does patients’ trust in doctors mediate the associations involved”).
between doctor-patient communication and the two outcomes
related to patient involvement? 2.3. Exposures

2. Methods In terms of doctor-patient communication, we focused on the

communication skills of doctors and the duration of patient consulta­
2.1. Data sources and study population tions. Specifically, four items (Cronbach’s alpha = 0.87) were selected to
examine patients’ perception of doctors’ communication skills on a
This study is based on data obtained from a cross-sectional telephone three-point scale (ranging from 1 = No to 3 = Yes, definitely). In the four
survey of Specialist Outpatient Experience (SOPE) in Hong Kong. Data items, the patient rated the doctor on awareness of medical history,
was collected in 27 public specialist outpatient clinics (SOPCs) between clarity of treatment explanations, attentiveness to viewpoints, and
July 2021 and January 2022. This survey questionnaire adopted the effectiveness in responding to care and treatment questions. Higher
short form of the “Specialist Outpatient Survey (SF-SOPEQ)”, developed aggregated scores across the four items (ranging from 4 to 12) indicated
with input from the Hospital Authority (HA) expert panel and the UK a higher level of doctor-patient communication skills. We used ten as the
patient experience framework [34] and validated by our research team conservative cutoff point to categorize doctors’ communication skills as
[35]. It was available in both English and Chinese. The telephone in­ “low” (≤ 10) and “high” (>10). We also conducted sensitivity analyses
terviews were conducted in Cantonese, Mandarin or English. Based on by exploring alternative continuous variable definitions for the

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C.Y. Tian et al. Patient Education and Counseling 129 (2024) 108410

parameter. Additionally, patients were asked to answer their consulta­ A, doctor communication skills → satisfaction with involvement in
tion duration with four options (i.e., “1 = up to 5 mins”, “2 = more than decision-making; model 4 A, patient consultation duration → satisfac­
5 mins to 10 mins”, “3 = more than 10 mins to 20 mins”, to “4 = more tion with involvement in decision-making. Logistic regression models do
than 20 mins”). Furthermore, for the classification of respondents’ not require independent and dependent variables to follow a specific
perception of their trust in the doctor’s examination and treatment, a distribution [39,40]. Additionally, given all these variables are cate­
single item with three responses (3 = “yes, definitely”, 2 = “yes, to some gorical, there is no need to normalize them if they have a skewed dis­
extent”, and 1 = “no”) was employed. Table A.1 (see appendix A) shows tribution [39,40].
the details of the variables and how they were scored. Next, to explore whether any variation in the outcomes could be
attributed to the clustering of patients within specific clinics with
2.4. Covariates varying levels of performance in SDM, we constructed four mixed-effect
models (1B, 2B, 3B, and 4B) augmenting the corresponding binary lo­
We utilized data on participants’ sociodemographic characteristics, gistic models with a random effect for clinics. Consistent with previous
including age, gender, educational attainment, living status, working patient experience surveys [36,41–43], the inclusion of the
status, and government allowance received. Additionally, patients’ case clinic-level factor had minimal impact on the odds ratios compared
groups (new VS. old cases), self-reported health status, and any long- with their corresponding binary logistic models (Table A.2, appen­
standing condition (including restriction in body movement, seeing dix A). Since the variation in outcomes was not primarily attributed
difficulty, hearing difficulty, speech difficulty, mental illness/mood to differences between clinics, we conducted mediation analyses [44]
disorder, autism, specific learning difficulties, and attention-deficit/ using regression models instead of mixed-effect models to assess
hyperactivity disorder) were collected. whether trust in the doctor mediates the association between
doctor-patient communication and involvement (i.e., the third
research question). Statistical significance was defined as a 2-sided P
2.5. Statistical analyses value < 0.05. We used R software (Version 4.1.2) for all analyses, which
were performed from September to November 2023. The conceptual
First, we described the proportion of patients who had been involved framework of this study can be found in Fig. 1.
in the treatment decision-making and those who were satisfied with the
involvement. We conducted Chi-square tests to examine the differences 3. Results
in patients’ characteristics, experience in communication with doctors,
and outcomes. To answer the first and second research questions, we 3.1. Characteristics of the study population
conducted four multivariable binary logistic regression models after
adjusting patients’ sociodemographic and health characteristics (i.e., The initial consent-seeking process by HA achieved a response
age, gender, education attainment, self-reported health status, and long- rate of 33.1 %, while the telephone interview by the trained in­
standing condition): model 1 A, doctor communication skills → terviewers from the research team garnered an 86.6 % response
perceived involvement in decision-making; model 2 A, patient consul­ rate, resulting in an overall response rate of 28.6 %. Overall, there
tation duration → perceived involvement in decision-making; model 3

Fig. 1. Conceptual Framework and Mediation Analysis. (Notes: the mediation analysis aimed to explore the association between the independent variable (X),
mediator (M), and dependent variable (Y); a path = the relationship between X and M; b path = the relationship between M and Y controlling for X; c path = the
total effect of the X on Y; c` path = the direct effect of X on Y controlling for M).

3
C.Y. Tian et al. Patient Education and Counseling 129 (2024) 108410

were 13,393 responses to the SOPE survey. We removed incomplete radiographer and an optometrist. These findings highlighted the critical
responses, including patients with no doctor consultation during role of doctor-patient communication in SDM.
the selected SOPC appointment or those who did not provide the
information required for the study’s analysis. This information 3.2. Perceived involvement in decision-making
included answers to key questions about the study outcomes, ex­
posures, and covariates. The final analytic sample contained Overall, 4463 (36.0%) participants perceived that they had not been
12,401 responses. Among the included respondents, 46.4 % were male, involved in decision-making about their treatment. In bivariate analysis,
and 11.7 % were aged between 18 and 40, 34.2 % were aged between the percentages of people who had not participated in decision-making
41 % and 60 %, and 54.1 % were aged 61 or above (roughly aligned were significantly higher among the elderly (aged > 60: non-involved
with the age and gender distribution of whole specialist outpatients in [60.8%] vs. involved [50.4%]), lower education group (primary and
Hong Kong in 2021 [45]). Over half of the respondents were below: non- involved [31.7%] vs. involved [26.1%]), patients with poor
well-educated (47%, secondary; 24.2%, postsecondary), employed health (non-involved [5.9%] vs.
(55%), reported good health status (57.2%, fair; 38.2% good), and did Involved [3.8%]), long-standing conditions (non-involved [10.3%]
not receive allowances from the government (69%). The majority were vs. involved [6.7%]), and those living without families (non-involved
follow-up cases at SOPCs (84.7%), lived with families (93.2%), and did [10.3%] vs involved [4.8%]), and those who were unemployed (non-
not have long-standing conditions (92%) (Table 1). Additionally, 70% involved [46.3%] vs involved [44.2%]), and who received an allowance
(8689) of respondents reported they only met/were attended by a doctor from the government (non-involved [35.3%] vs involved [28.6%])
without other healthcare professionals for this appointment. Of the (Table 1).
remaining respondents who met with both a doctor and other pro­
fessionals, 21.7% (2697) mentioned interacting primarily with a nurse,
while others reported interactions with other professionals such as a

Table 1
Distribution of respondents’ sociodemographic and health status.
Variable Total Perceived involvement in decision-making Satisfaction with involvement in decision-making
(N = 12401)
Non-involved Involved P value Dissatisfied Satisfied P value
(N = 4463) (N = 7938) (N = 5515) (N = 6886)

Sex 0.87 0.004**

Male 5754 (46.4) 2066 (46.3) 3688 (46.5) 2478 (44.9) 3276 (47.6)
Female 6647 (53.6) 2397 (53.7) 4250 (53.5) 3037 (55.1) 3610 (26.4)
Age group <0.001 0.001**
***
18 − 40 1452 (11.7) 410 (9.2) 1042 (13.1) 666 (12.1) 786 (11.4)
41 − 60 4237 (34.2) 1341 (30.0) 2898 (36.5) 1964 (35.6) 2273 (33.0)
> 60 6712 (54.1) 2712 (60.8) 4000 (50.4) 2885 (52.3) 3827 (55.6)
Education <0.001 0.62
***
Primary and below 3483 (28.1) 1413 (31.7) 20710(26.1) 1553 (28.2) 1930 (28.0)
Secondary 5917 (47.7) 2081(46.6) 3836 (48.3) 2650 (48.1) 3267 (47.4)
Post-secondary 3001(24.2) 969 (21.7) 2032 (25.6) 1312 (23.8) 1689 (24.5)
Health Status <0.001 <0.001
*** ***
Poor 563 (4.5) 263 (5.9) 300 (3.8) 200 (3.6) 363 (5.3)
Fair 7096(57.2) 2105 (47.2) 4995 (62.9) 3373 (61.2) 3723 (54.1)
Good 4742 (38.2) 2095 (46.9) 2647 (33.3) 1942 (35.2) 2800 (40.7)
Case group 0.81 0.04*
New case 1892 (15.3) 686 (15.4) 1206 (15.2) 801 (14.5) 1091 (15.8)
Old case 10509 (84.7) 3777 (84.6) 6732 (84.8) 4714 (84.5) 5795 (84.2)
Loog-standing conditiona <0.001 0.05
***
No 11409 (92.0) 4003 (89.7) 7406 (93.3) 5044 (91.5) 6365 (92.4)
Yes 992 (8.0) 460 (10.3) 532 (6.7) 471 (8.5) 521 (7.6)
Living status <0.001 0.009***
***
Live with families 11573 (93.2) 4014 (89.7) 7559 (95.2) 5178 (93.9) 6382 (92.7)
Live without families 844 (6.8) 461 (10.3) 383 (4.8) 337 (6.1) 504 (7.3)
Working status 0.02* 0.015**
Employedb 6839 (55.1) 2404 (53.7) 4435 (55.8) 2970 (53.9) 3860 (56.1)
Unemployedc 5578 (44.9) 2071 (46.3) 3507 (44.2) 2545 (46.1) 3026 (43.9)
Received allowance from <0.001 <0.001
government *** ***
No 8571 (69.0) 2887 (64.9) 5670 (71.4) 3805 (69.0) 4752 (69.0)
Yes 3856 (31.0) 1576 (35.3) 2268 (28.6) 1710 (31.0) 2134 (31.0)

(Notes: data are presented as the number of the participants in each category (n), together with the column percentage (%), p-values are obtained from the Chi-square
test of variances;
a
= includes restriction in body movement, seeing difficulty, hearing difficulty, speech difficulty, mental illness/mood disorder, autism, specific learning difficulties,
attention-deficit/hyperactivity disorder;
b
= includes full-time worker/student, home-maker, part-time worker;
c
= includes retired and unemployed;
*
= P < 0.05;
**
= P < 0.01;
***
= P < 0.001)

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C.Y. Tian et al. Patient Education and Counseling 129 (2024) 108410

3.3. Satisfaction with involvement in decision-making than the total effect (c) (Mediation model 1: c [− 0.28] vs. c` [− 0.48];
Mediation model 2: c [− 0.34] vs. c` [− 0.36]), highlighting the sup­
Over half (6886, 55.5%) of respondents reported being satisfied with pressive role of the mediator: trust in doctors, in the two models. In
their involvement in decision-making. Among non-involved re­ Mediation model 3, however, the b path was not significant, suggesting
spondents, 67.4% expressed satisfaction with their level of involvement, there was no mediation effect of trust in doctors on the association be­
24.4% wanted less involvement, and only 8.3% wanted more involve­ tween doctors’ communication skills and patients’ involvement in
ment. By contrast, 48.9% of the involved respondents felt satisfied with decision-making. Mediation model 4 exhibited significant positive as­
their level of involvement, 2.2% desired less involvement, and 48.9% sociations in all paths (a path: 0.08, P < 0.001; b path:0.68, P < .001; c
wanted more involvement. Moreover, significantly higher proportions path: 0.65, P < .001; c` path: 0.61, P < .001), indicating that trust in
of satisfaction with the involvement were observed among males doctors acted as a mediator in this model.
(satisfied vs. dissatisfied: 47.6% vs. 44.9%), elderly aged 60 or above
(satisfied vs. dissatisfied: 55.6% vs. 52.3%), new cases (satisfied vs. 4. Discussion and conclusion
dissatisfied: 15.8% vs. 14.5%), and those who reported poor (satisfied
vs. dissatisfied: 5.3% vs. 3.6%) or good health (satisfied vs. dissatisfied: 4.1. Discussion
40.7% vs. 35.2%), were employed (satisfied vs. dissatisfied: 56.1% vs.
53.9%), and live without families (satisfied vs dissatisfied: 7.3% vs This study observed a limited level of patient involvement in
6.1%) (Table 1). healthcare decision-making at outpatient service, consistent with the
findings of previous studies in outpatients [46–48]. Similar to previous
3.4. Association between doctor-patient communication and involvement literature [46,47,49,50], the present study reveals concerns that the
in decision-making proportion of those not being involved in decision-making was higher
among socially disadvantaged groups and unhealthy populations.
In the bivariate analysis, doctor-patient communication was signif­ Developing strategies and interventions that consider these disparities is
icantly associated with patients’ involvement in decision-making and imperative to ensure equitable and patient-centered healthcare prac­
their satisfaction with the involvement (Table 2). In the multivariable tices. Additionally, explaining or predicting the preferences of patient
regression models 1 A and 2 A, the results suggested that patients who involvement in decision-making remains challenging. In line with
rated their doctor as having better communication skills were less likely earlier research [51–53], this study revealed variability in individuals
to be involved in decision-making (odd ratio, 0.76 [95% CI, 0.67–0.85], who felt satisfied with their participation in medical decision-making.
P < .001) but more likely to report satisfaction with their level of For instance, it found that health status was not the primary factor
involvement (odd ratio, 6.88 [95% CI, 5.99–7.93], P < .001). Similarly, influencing patients’ satisfaction with involvement in medical
in models 3 A and 4 A, patients with longer consultation duration were decision-making, following the findings of one systematic review [16];
less likely to be involved in decision-making (odd ratio, 0.71 [95% CI, however, Rencz et al. found that patients with chronic illness were more
0.66–0.73], P < .001) but more likely satisfied with their involvement likely to experience satisfaction with their desired and actual
(odd ratio, 1.91 [95% CI, 1.80–2.04], P < .001) (Table 3). Sensitivity involvement in medical decisions [7]. Therefore, further research is
analysis confirmed the findings in models 1 A and 3 A (Table A.3, ap­ warranted to delve deeper into the motivations and factors that underlie
pendix A). these preferences.
Despite certain studies indicating a potential correlation between
3.5. Mediation analyses for trust in doctors improved communication and increased SDM [54,55], our study chal­
lenged this assumption. We discovered that doctors’ better communi­
As shown in Fig. 2, in Mediation models 1 and 2 we observed sig­ cation skills were not adequate to increase patients’ involvement in
nificant positive associations between doctor communication skills/pa­ shared decision-making. One potential explanation for these findings is
tient consultation time and trust in doctors (a path in Mediation model 1: the cultural influences. Current evidence suggests that patients in Hong
0.76, P < .001; a path in Mediation model 2: 0.08, P < .001) and be­ Kong more commonly prefer doctor-directed (or paternalistic) care and
tween trust in doctors and patients’ perceived involvement in decision- assume conventional passive roles in healthcare consultations [56–58].
making (b path in Mediation model 1: 0.26, P < .001; b path in Medi­ As highlighted by the theoretical framework on the effect of culture on
ation model 2: 0.15, P < .001). Notably, both c and c` paths exhibited the application of the patient-physician relationship in the Asian
significant negative relationships, and the direct effect (c`) was larger healthcare context, the Confusion philosophy underlying many Asian

Table 2
Bivariate relationships between doctor-patient communication and involvement in decision-making.
Perceived involvement in decision-making Satisfaction with involvement in decision-making

Non-involved Involved P value Dissatisfied Satisfied P value

Doctors’ communication skills <.001*** <.001***

Low 437 (9.8) 995 (12.5) 1169 (21.2) 263 (3.8)
High 4026 (90.2) 6943 (87.5) 4346 (78.8) 6623 (96.2)
Consultation time <.001*** <.001***
< 5 min 1420 (31.8) 3651 (46.0) 2966 (53.8) 2105 (30.6)
5 - 10 min 2145 (48.1) 3212 (40.5) 1998 (36.2) 3359 (48.8)
10 - 20 min 764 (17.1) 975 (12.3) 492 (8.9) 1247 (18.1)
> 20 min 134 (3.0) 100 (1.3) 59 (1.1) 175 (2.5)
Trust in doctors 0.002** <.001***
Distrust 121 (2.7) 145 (1.8) 225 (4.1) 41 (0.6)
Partially trust 564 (12.6) 1070 (13.5) 946 (17.2） 688 (10.0）
Fully trust 3778 (84.7) 6723 (84.7) 5290 (95.9) 6845 (99.4)

(Notes: data are presented as the number of the participants in each category (n), together with the column percentage (%), p-values are obtained from the Chi-square
test of variances,
**
= P < 0.01;
***
= P < 0.001)

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C.Y. Tian et al. Patient Education and Counseling 129 (2024) 108410

Table 3
Relationships between doctor-patient communication and involvement in decision-making estimated from the regression models #.
Perceived involvement in decision-makinga Satisfaction with involvement in decision-makingb

Model 1 A Model 2 A Model 3 A Model 4 A

OR (95% CI) P value OR (95% CI) P value OR (95% CI) P value OR (95% CI) P value
Doctors’ communication skills: 0.76 (0.67 - 0.85) < .001 / / 6.88 (5.99 - 7.93) < .001 / /
High *** ***
Consultation time / / 0.71 (0.66 - 0.73) < .001 / / 1.91 (1.80 - 2.04) < .001
*** ***
Sex: Female 0.92 (0.85 - 0.99) .03* 0.90 (0.83 - 0.97) .01** 0.97 (0.90 - 1.04) 0.37 0.97 (0.90 – 1.04) 0.41
Age
18 − 40 Ref Ref Ref Ref
41 − 60 0.75 (0.65 - 0.87) < .001 0.74 (0.64 - 0.85) < .001 1.1 (0.96 - 1.25) 0.16 1.11 (0.97 - 1.26) 0.12
*** ***
> 60 0.49 (0.42 - 0.57) < .001 0.49 (0.43 - 0.57) < .001 1.35 (1.18 - 1.54) < .001 1.30 (1.13 - 1.48) < .001
*** *** *** ***
Education
Primary and below Ref Ref Ref Ref
Secondary 1.14 (1.04 - 1.25) .001** 1.16 (1.06 - 1.28) .002** 1.06 (0.97 - 1.17) 0.22 1.01 (0.92 - 1.11) 0.81
Post-secondary 1.27 (1.12 - 1.43) < .001 1.29 (1.14 - 1.45) < .001 1.13 (1.01 - 1.27) .04* 1.06 (1.10 - 1.62) 0.32
*** ***
Health status
Good Ref Ref Ref Ref
Fair 2.32 (2.13 - 2.52) < .001 2.18 (1.48 - 2.12) < .001 0.76 (0.70 - 0.82) < .001 0.85 (0.79 - 0.92) < .001
*** *** *** ***
Poor 1.22 (0.09 - 2.15) .03* 1.23 (0.68 - 0.98) .03* 1.49 (1.22 - 1.82) < .001 1.34 (1.10 - 1.62) .003**
***
Long-standing condition: Yes 0.63 (0.67 - 0.85) < .001 0.65 (0.57 - 0.75) < .001 0.89 (0.78 - 1.03) 0.12 0.78 (1.82 - 2.02) < .001
*** *** ***

(Notes:
a
= binary variable, non-involved was coded as 0, involved was coded as 1;
b
= binary variable, dissatisfied was coded as 0, satisficed was coded as 1;
*
= P < 0.05;
**
= P < 0.01;
***
= P < 0.001)

Fig. 2. Results of mediation analysis. (Notes: the mediation analysis aimed to explore the association between the independent variable (X), mediator (M), and
dependent variable (Y); a path = the relationship between X and M; b path = the relationship between M and Y controlling for X; c path = the total effect of the X on
Y; c` path = the direct effect of X on Y controlling for M; * * = P < 0.01; * ** = P < 0.001).

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C.Y. Tian et al. Patient Education and Counseling 129 (2024) 108410

cultures emphasized harmony and respect for authority [59]. With this could be inferred by this cross-sectional study. Second, it might be
in mind, even when patients perceive their doctors to possess possible that some patients underestimate their actual levels of
commendable communication skills and allocate sufficient consultation involvement. Due to the complexity of this concept, it is a challenge to
time, they may still be inclined toward delegating the responsibility for evaluate and measure how patients perceive and are involved in the
medical decision-making to their healthcare providers. Furthermore, decision process. Even the most used measurement tools for SDM
limited health literacy and knowledge about available treatment options (including the OPTION scale [74]) mainly focus on physician behaviors
may also contribute to patients’ reluctance to engage in decision-making and thus may be missing important aspects of the interaction in patient
[49,60,61]. This issue is especially pertinent in specialist outpatient engagement in decision-making. In the present study, the outcome
settings, where patients often encounter the intricacies of their medical measures of patient involvement valued patients’ subjective overall
conditions. Consequently, some patients might mainly rely on their feelings (not just being) of involvement, aligning with approaches
healthcare providers’ guidance. Considering the high prevalence of observed in previous studies [36–38]. Third, due to limited resources,
limited health literacy in Hong Kong [62–64], more health education we were not able to assess whether doctors’ characteristics did indeed
programs and workshops for patients are needed to promote their impact patients’ involvement. Fourth, this survey was the third wave of
involvement in medical decision-making. the SOPE survey, following those conducted in 2014 and 2018. Although
Furthermore, the observed negative association between consulta­ the five-point Likert scale of doctor communication skills allows for a
tion length and patient involvement in decision-making highlighted the more nuanced range of options, our survey kept the initial three-point
complexity of SDM. Particularly, one recent systematic review suggested Likert scale allowing for a comprehensive analysis of trends and iden­
that consultation length was not associated with patient involvement in tifying potential areas for improvement in healthcare services over time.
decision-making [65]; however, local healthcare professionals empha­
sized that time constraint was a crucial barrier to involving patients 4.2. Conclusion
[56]. Within the scope of our study from the patient perspective, the
adverse impact of consultation time underscores that lengthy consulta­ This study of a representative sample of specialist outpatients in
tions may introduce a significant amount of medical information, and Hong Kong provides insights into the association between doctor-patient
patients still tend to adopt passive roles. Consequently, this overload communication, trust in doctors, and patient involvement in decision-
might generate confusion and uncertainty, leading patients to defer to making. These findings suggest an unexpected trend where better
their doctor’s judgment. In such situations, clinicians are encouraged to doctor-patient communication is negatively associated with patients’
utilize specific approaches for effectively addressing passive patients. participation in medical decision-making, potentially due to patients
These approaches may include responding to their salient emotional assuming passive roles and limited health literacy in medical consulta­
cues, normalizing distress, and confirming their comprehension. tion. Building trust in doctors may be a valuable strategy for promoting
In this study, we found that patients who reported better doctor- active participation in decision-making, as it partially suppresses doctor-
patient communication were more likely to feel satisfied with their patient communication’s adverse impact on involvement. Moreover,
involvement in decision-making. As documented in existing literature, good doctor-patient communication and trust in doctors positively
physicians’ communication behaviours [66,67] and consultation dura­ contributed to the patient’s satisfaction with their involvement in
tion [68,69] both have a significant impact on patients’ overall satis­ decision-making. Although these findings are preliminary, they raise
faction with their experience in healthcare practices. This implies that concerns that SDM in practice may be far from what is intended by
minor adjustments in physicians’ communication practices, such as guidelines. Clinics should consider individual patients’ preferences and
soliciting patient opinions, providing opportunities for patients to share capabilities when tailoring communication strategies about SDM to
their experiences, actively encouraging them to seek clarification, and optimize patient satisfaction.
ensuring adequate consultation time, might significantly influence the
quality of care they receive. 5. Practice implications
We observed trust in doctors significantly suppressed the negative
effect of doctor-patient communication on patients’ participation in Currently, we are unaware of any formal strategic plan to introduce
decision-making. As highlighted in earlier research, trust in healthcare SDM in Hong Kong. Using a large and representative sample, this study
significantly impacts how patients evaluate treatment-related risks and identified different groups of patients at greater risk of undergoing
benefits, subsequently influencing their intentions to engage in medical negative experience of involvement in decision-making. This profiling
decision-making and shaping their emotional responses [70,71]. In can help inform priorities for further research and improvement efforts.
addition, consultation duration per se was not the key factor to drive Given the variety of patients’ preferences with the involvement, more
patients’ satisfaction with SDM. Instead, patients’ trust in doctors, a qualitative studies are needed to explore the factors that underlie these
factor that can be enhanced through longer consultation durations, preferences. Medical training also should place more emphasis on how
positively influences their overall satisfaction with their engagement in to actively seek and understand patients’ views, feelings, and prefer­
the decision-making process. These observations underscore the ences regarding their health and treatment.
importance of fostering trust as a fundamental element in building In addition, the observed negative association between doctor-
communication skills for achieving patient satisfaction and active patient communication and patient involvement in our current
involvement in decision-making. Being transparent about the treatment study and other similar research [75,76], highlighted more dis­
process and potential risks, addressing concerns, demonstrating cussion is needed to explore why effective communication doesn’t
empathy, and eliciting and respecting patients’ values and preferences always translate into increased patient involvement. These discus­
are useful strategies for doctors to build trust with their patients [72,73]. sions could consider perspective from both doctors and patients. From
Patients who trusted their doctor were more likely to feel comfortable the doctors’ perspective, factors such as time constraints, workload, and
sharing their concerns, so they would feel their values and preferences varying communication styles may impact how effectively they can
were respected in the conversation; and participate in the engage patients; while from the patients’ perspective, there might be
decision-making process of treatment and care. It turns out that the barriers such as health literacy, personal beliefs, or past experiences that
doctors would then be more willing to elicit patient’s values and ex­ influence their level of involvement. Understanding these dynamics
change their views with patients. This constitutes a virtuous cycle of between patient-doctor interaction requires qualitative and quantitative
patient-doctor trust for SDM, which can not only increases patients’ methods to explore factors influencing SDM. Accessing such knowledge,
health literacy but also builds the foundation of person-centric care. may help identify strategies to bridge the gap between communication
This study possesses some limitations. First, no causal relationship and patient involvement, ensuring that effective communication truly

7
C.Y. Tian et al. Patient Education and Counseling 129 (2024) 108410

leads to better patient engagement and outcomes. acquisition, Data curation, Conceptualization.

Ethics statement Declaration of Competing Interest

The study adhered to the principles outlined in the Declaration of The authors declare that they have no known competing financial
Helsinki and received approval from the relevant local clinical research interests or personal relationships that could have appeared to influence
ethics committee. Informed consent for participation in the study was the work reported in this paper.
obtained before the survey.
Data availability statement
Funding
The datasets generated and/or analyzed during the current study are
There is no funding support for the study. not publicly available to protect the anonymity of participants but are
available from the corresponding author upon reasonable request.
CRediT authorship contribution statement
Acknowledgments
Eng-Kiong Yeoh: Supervision, Funding acquisition. Kailu Wang:
Writing – review & editing, Methodology. Annie Wai-Ling Cheung: The original study survey was commissioned by the Hong Kong
Project administration, Funding acquisition. Hong Qiu: Writing – re­ Hospital Authority, and we would like to thank all participants who
view & editing, Methodology. Shi Zhao: Writing – review & editing, participated in the survey. We also wish to thank the Hong Kong Hos­
Methodology. Cindy Yue Tian: Writing – review & editing, Writing – pital Authority for their assistance in conducting the study. The financial
original draft, Methodology, Formal analysis, Conceptualization. Eliza support of the Centre for Health Systems and Policy Research is from The
Lai-Yi Wong: Writing – review & editing, Supervision, Funding Tung’s Foundation.

Appendix

Table A.1
Question wording and scoring of variables of interests.

Variable Question wording Scoring

Perceived involvement of Were you involved in decision about your care and treatment (including Scale from 1 to 3 ( ranging from "1 = No", "2 = Yes, to some extent"
decision-making prescriptions)? to "3 = Yes, definitely")
Satisfaction with involvement Did you like to be more or less involved in decisions about your care and Scale from 1 to 3 ( ranging from "1 = No", "2 = Yes, to some extent"
of decision-making treatment (including prescriptions)? to "3 = Yes, definitely")
Doctor-patient
communication
Doctor communication skills How was the doctor’s awareness of your medical history? Scale from 4 to 12 (each item with three response options from
Did the doctor explain the reasons for any treatment or action in a way that "1 = No", "2 = Yes, to some extent" to "3 = Yes, definitely")
you could understand?
Did the doctor listen to your views?
When you had important questions to ask the doctor about your care and
treatment, did the doctor provide a clear and understandable answer to
you?
Patient consultation time Did you have enough time to discuss your health or medical problem with Scale from 1 to 4 ("1 = up to 5 mins", "2 = more than 5 mins to
the doctor? 10 mins", "3 = more than 10 mins to 20 mins", to "4 = more than
20 mins)
Trust in doctors Did you have trust in the doctor examining and treating you? Scale from 1 to 3 ( ranging from "1 = No", "2 = Yes, to some extent"
to "3 = Yes, definitely")

Table A.2
Relationships between doctor-patient communication and involvement in decision-making estimated from the regression models and mixed-effect models.

OR adjusted for patient characteristics (95% CI)# OR adjusted for patient characteristics and hospital (95% CI)^

Outcome: Perceived involvement Outcome: Satisfaction with Outcome: Perceived involvement Outcome: Satisfaction with
in decision-making involvement in decision-making in decision-making involvement in decision-making

Model 1 A Model 3 A Model 1B Model 3B

Doctor communication 0.75 (0.88 - 0.94)*** 6.88 (5.99 – 7.93)*** 0.75 (0.66 - 0.84)*** 7.24 (6.28 – 8.34)***
skills
Model 2 A Model 4 A Model 2B Model 4B
Patient consultation 0.71 (0.66 - 0.73)*** 1.91 (1.80 - 2.04)*** 0.72 (0.68 - 0.75)*** 1.94 (1.84 - 2.05)***
duration
Note: # = the regression model was adjusted for patient characteristics (including age, gender, education attainment, health status, and long-standing condition); ^
= the mixed-effect model was adjusted for patient characteristics (including age, gender, education attainment, health status, and long-standing condition) and
included clinic-level factor as a random effect; a = binary variable, non-involved was coded as 0, involved was coded as 1; b = binary variable, dissatisfied was coded as
0, satisficed was coded as 1;
***
= p < 0.001

8
C.Y. Tian et al. Patient Education and Counseling 129 (2024) 108410

Table A.3
Relationships between doctor-patient communication and involvement in decision-making estimated from the regression models #.

Variable Perceived involvement in decision-makinga Satisfaction with involvement in decision-makingb

Model 1 A Model 3 A

Doctors’ communication skills^ 0.98 (0.97 - 0.99) < .001*** 1.11 (1.10 – 1.12) < .001***
Covariate
Sex: Female 0.98 (0.97 - 1.00) .03* 0.99 (0.97 - 1.01) 0.3
Age
18 − 40 Ref Ref
41 − 60 0.94 (0.91 - 0.97) < .001*** 1.02 (0.99 - 1.05) 0.15
> 60 0.86 (0.83 - 0.88) < .001*** 1.07 (1.03 - 1.10) < .001***
Education
Primary and below Ref Ref
Secondary 1.03 (1.01 - 1.05) .001** 1.01 (0.99 - 1.04) 0.19
Post-secondary 1.05 (1.03 - 1.08) < .001*** 1.03 (1.00 - 1.06) .03*
Health status
Good Ref Ref
Fair 1.21 (1.18- 1.23) < .001*** 0.94 (0.92 - 0.96) < .001***
Poor 1.04 (1.00 - 1.08) 0.07 1.10 (1.05 - 1.15) < .001***
Long-standing condition: Yes 0.98 (0.97 - 0.99) < .001*** 0.97 (0.94 - 1.00) 0.07
(Notes: a = binary variable, non-involved was coded as 0, involved was coded as 1; b = binary variable, dissatisfied was coded as 0, satisficed was coded as 1; ^ =
continuous variable;
*
= p < 0.05;
**
= p < 0.01;
***
= p < 0.001)

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