Where is the problem to be solved? Problem defining and epistemic uncertainties in shared decision-making.

Abstract

Physicians and patients apply different but overlapped knowledge in their contexts to define the divergent problems to solve during cancer treatment. This study aims to identify the knowledge sources of problem defining between physicians and patients in shared decision-making on cancer treatment. This study adopted a divided narrative approach and interviewed 32 cancer patients and their paired 16 physicians from two top hospitals in northwestern China. Physicians defined problems by five types of knowledge sources structured in the social system and patients defined problems by five types of knowledge sources grounded in the individual system. Physicians and patients draw knowledge to define problems through asymmetric social mechanisms, which demonstrates the structural and cultural barriers to reaching mutual understanding and trust. However, a shared definition of the problem emerges from epistemic uncertainties in physician-patient interaction. Problem defining unfolds a chain of problems in shared decision-making, which can be potentially solved through narrative exchange at macro, meso, and micro levels. This study suggests that, in shared decision-making, physicians can pay more attention to the cultural aspects of patients' problem-defining narratives, while patients can be more aware of the social structural aspects of physicians' problem-defining narratives.