Effect of medical students’ values on their clinical decision-making

KEYWORDS: Decision-making; social values; students; medical; New Zealand; professional practice

Decision-making is influenced by a variety of factors such as individuals’ experiences, skills, values, habits, personal perceptions and availability of information and time.^1,2 Clinical decision-making may also be influenced by personal and professional values of health-care practitioners,^3,4 resulting in personal biases in clinical decisions, which can compromise the quality of patient care. Clinicians may be unaware of their biases.⁵ To reduce health-care practitioner biases and facilitate patient involvement in decision-making, current practices promote patient-centred and shared decision-making models that incorporate the values, preferences and social circumstances of patients into clinical decisions.^6–8 Some educators have suggested that improving the health-care practitioners’ awareness of their own values and how these values influence their decision-making may help reduce their personal biases and deliver more patient-centred decisions.^9,10

There is little research on the relationship between clinicians’ values and decision-making,^11,12 and whatever is available has largely focused on decision-making on general ethical dilemmas, not on situations typical in clinical practice. Existing studies focus on the relationship between values and specific skills including problem-solving in nursing students,¹³ ethical decision-making in medical and dental students,¹¹ and moral development in medical students.¹² The nursing student study¹³ investigated students’ decision-making abilities using an instrument that measured their confidence with problem-solving,¹⁴ and the other two^11,12 measured decision-making abilities using case-based assessments, with students selecting decision alternatives from a panel that included some alternatives that were ethically correct or preferable to others. In these studies, the case scenarios used were general ethical dilemmas, not specific to decision-making in clinician–patient interactions.

Nevertheless, findings from these studies^11–13 and others^15–17 indicate associations between values and decision-making. Nursing students who prioritised values of truth and human dignity, as defined by the American Association of Nursing Colleges,¹⁸ showed greater confidence in problem-solving than other students.¹³ Conversely, medical and dental students who prioritised the value of comfort over equality, as measured by the Rokeach Values Survey,¹⁹ showed poorer ethical decision-making abilities than other students.¹¹ Medical students who prioritised the value of universalism, as measured by the Schwart Values Survey,²⁰ showed greater moral decision-making abilities than other students, while students who prioritised the values of power and achievement showed poorer moral decision-making abilities.¹²

In contrast to the general ethical dilemmas in these studies,^11,12 decision-making in everyday practice often involves cases where there is no consensus on which decisions are right or wrong, or best for individual patients.^21,22 Clinical decisions often involve consideration of many factors including the clinical problem, investigation data, patients’ values, patients’ family and social circumstances, practice environment, organisation and legislation environments, and health-care practitioners’ capabilities and values.^23,24 Successfully negotiating these factors to make decisions that have optimum outcomes for patients reflects clinicians’ decision-making skills in the context of actual practice.²⁵

Our aim was to identify how medical students’ values influence their decision-making with patients in everyday general practice situations. Rather than use multiple choice testing with given right and wrong alternatives to measure students’ decision-making,^11,12 we aimed to identify the factors different students consider in decision-making in different clinical contexts, and investigate how these are influenced by the students’ values. We used a value measurement instrument designed to measure values relevant to decision-making in health care.^26,27 This instrument uses Schwartz’s values model²⁰ as a framework, but its content is contextualised to health-care practice. The advantages of this approach are that the framework comprehensively covers key values that guide human decision-making, and it has been validated across cultures.^20,28,29

Our specific objectives were to determine:

1. What factors are commonly considered by medical students in clinical decision-making in different clinical contexts?

2. How do differences in value priorities between medical students influence their decision-making in given clinical contexts?

3. Which values are likely to influence the type of factors that medical students consider in making decisions in different clinical contexts?

We invited into the study all students completing Year 5 in the 6-year medical programme at the University of Auckland. Years 4 and 5 focus on hospital and community clinical practice in disciplines including general practice, psychiatry, medicine and surgery. Problem-based and case-based learning are used. Students are exposed to complex real-world contexts to prepare them for their trainee internship in Year 6. The study was approved by the University of Auckland Human Participants Ethics Committee (Reference 011073/2014). The survey was conducted in two parts:

The health-care practitioner values scale (HPVS) organises personal and professional values of health-care practitioners identified from literature^26,27 within the Schwartz values model.²⁰ The HPVS incorporates 11 health-care practitioner personal and professional values: authority, capability, pleasure, intellectual stimulation, critical thinking, equality, altruism, spirituality, tradition, professionalism and safety.²⁶ Participants were asked to rank these values according to the importance of each to them as a guiding principle in their health-care practice. The most important value was ranked 1 and the least important ranked 11.

Participants were asked to list as many issues and considerations that matter to them and their patient in coming to a clinical decision for each of four clinical scenarios (Table 1). They were not required to rank them. The scenarios represented cases where there are no clear-cut right or wrong decisions. They were developed and validated with a group of general practitioners. A worked example and the following instruction for completing this section were given: ‘For each of the following four scenarios please list as many things as you think may be relevant (e.g. in bullet point form) about the issues and considerations that would matter to you and your patient in coming to a clinical decision’.

Table 1. Survey clinical scenarios

We used a general inductive approach for thematic analysis of qualitative data³⁰ to identify factors considered in making a decision for each clinical scenario. Key factors were identified, coded and synthesised for each scenario by two researchers independently. Discrepancies were resolved with adjudication.

For each clinical scenario, ranked value priorities (measured by ranking) for participants who identified a particular factor in making their decision were compared between participants who identified or did not identify a factor as important. We used Welch’s t-test to evaluate the difference between mean value priorities, and Cohen’s d to estimate the effect size of the differences. Our null hypothesis was that there were no differences in mean value priorities of participants who did and did not consider a particular factor in making a clinical decision in a given scenario.

To highlight key differences in value priorities across factors in the four clinical scenarios, data with significant differences (P < 0.05) and significant effect sizes (Cohen’s d > 0.3) were tabulated. The patterns in the selected data were analysed to understand how differences in value priorities between medical students influenced their choice of factors in given clinical contexts.

For all clinical scenario and factor combinations, we computed differences in value priorities between students who considered a given factor in their decision and students who did not consider the same factor. For example, 24 data points for the value of altruism consisted of differences in altruism ranks between students who considered the patient’s perspective and those who did not in each of the four clinical scenarios, differences in altruism ranks between students who considered family and social circumstances and those who did not, and so on for each decision factor in the four scenarios. Similar differences were computed for each value in turn.

We explored variation in value priority differences (rank differences) for each value using a boxplot. If given values showed larger variation in rank differences across factors and scenarios, this would indicate that these values were more likely to influence the factors students considered in decision-making in different contexts than other values. We then analysed the rank differences for each value using a random effects model. Our rationale was that there are many clinical scenarios (contexts) that can arise in clinical practice, and many factors that can be considered in a clinical scenario, so we analysed the clinical scenarios and the factors as random observations from populations of clinical scenarios and factors. For each value, we used a random effects model to estimate variance components for the rank differences between students who considered a given factor in their decision and those who did not. The rank differences were modelled as a dependent variable against clinical scenarios and factors considered in decision-making, which were modelled as random independent variables. The variance components estimated were the proportions of variation in rank differences that were explained by random clinical scenarios, random factors in decision-making and residual error for each value. If the proportion of variation explained by clinical scenarios or factors considered in decision-making was significant for particular values, this would imply that the given values were likely to influence the choice of factors considered in decision-making in different clinical contexts.

From a class of 240 medical students, 117 (49%) participated in our survey.

We identified six major factors students considered in decision-making: patient perspective, family and social circumstances, patient safety, symptoms and treatment efficacy, health-care practitioner self-awareness, and service cost (Table 2). We grouped these into three categories by considering the aspects of clinical decision-making on which they focused: patient-centred (patient perspective, family and social circumstances); clinical (patient safety, symptoms and treatment efficacy); and situational (health-care practitioner self-awareness, service cost). Inter-rater agreement in organising text segments into the six decision factors was 96.5%. We reached full consensus on the classification of the texts into themes after adjudication.

Table 2. Factors considered by students in clinical decision-making

Significant value priority differences (P < 0.05, Cohen’s d > 0.3) between students who selected different factors in making clinical decisions are shown in Table 3 and are summarised below:

(i) In the End-of-life and Botox scenarios, students who ranked spirituality higher considered patient-centred factors more frequently.

(ii) In the prostate specific antigen (PSA), Roaccutane and End-of-life scenarios, students who ranked spirituality higher considered clinical factors less frequently.

(iii) In the Roaccutane and Botox scenarios, students who ranked critical-thinking higher considered patient-centred factors less frequently.

(iv) In the Botox, End-of-life and PSA scenarios, students who considered situational factors ranked capability, professionalism and safety values higher, respectively.

Table 3. Comparison of value priorities of students who chose different decision factors

In the data from all clinical scenarios, spirituality and critical thinking showed the greatest variations in value priority differences between students who considered a given factor in their decision and students who did not consider the same factor (Fig. 1). Value priority differences for altruism, authority, capability, equality and morality also showed considerably higher variation compared to values of intellectual stimulation, pleasure, professionalism and safety. From variance component analysis, the total proportion of variance in value priority differences explained by random decision factors and clinical scenarios was highest for critical thinking (56%) and spirituality (25%) values (Table 4; Fig. 2).

Figure 1. Value differences between students who considered a given decision factor and those who did not in each of the clinical scenarios. Spirituality and critical thinking showed the greatest variation in value rank differences between students who considered a given decision factor and those who did not consider the same factor

Table 4. Variance components of value differences across decision factors and clinical scenarios

Figure 2. Variance components of values across decision factors and clinical scenarios. Spirituality and critically thinking showed the highest variance in the value rank differences across decision factor and scenarios. The two values also showed considerable proportion of variance explained by changing decision factors and clinical scenarios

Our content analysis identified six major factors that medical students consider in clinical decision-making, and we organised these into three categories: patient-centred, clinical and situational. Overall, our findings suggest that spirituality and critical thinking are the two values that are most likely to influence factors medical students consider in their clinical decisions. Students who prioritise spirituality are more likely to consider patient-centred factors, and less likely to consider clinical factors than other students in some contexts. Students who prioritise critical-thinking are less likely to consider patient-centred factors in some contexts compared to other students. Students who prioritise capability, professionalism and safety values are more likely to consider situational factors relevant to a given case than other students.

The factors influencing clinical decision-making that we identified in this study are consistent with factors discussed in literature.^24,31 Our new finding is that patient-centred factors were the most prominent factors medical students considered in their decision-making. Patient-centred decision-making approaches have been widely promoted in medical education in recent decades, and medical students may also adopt patient-centred decision-making approaches as a result.^32–34 Other studies also indicate that medical students demonstrate considerable patient-centred attitudes in their clinical practice.^35–37

We found that spirituality was the most prominent value associated with differences in students’ decision-making approaches. This is consistent with other studies, which indicate that many clinicians acknowledge that their spirituality influences their clinical decisions.^38–41 Specifically, our findings indicate that students who prioritise spirituality favour patient-centred factors in decision-making. This agrees with one study that showed a positive correlation between spirituality and patient-centred approaches to decision-making.⁴² Furthermore, we found that the influence of spirituality on clinical decision-making depends on the clinical context, which is consistent with other studies.^38,43,44 Clinicians are more willing to consider spirituality in contexts involving dying than in any other contexts.⁴³ Finally, our finding on the negative correlation between spirituality and evaluation of clinical factors in clinical decision-making is a concern. We found no studies exploring this relationship, so it may require further investigation.

Critical thinking was the second most prominent value associated with differences in students’ decision-making approaches, after spirituality. In two scenarios where patients requested specific treatments, we observed that students who ranked the critical thinking value high were less inclined to consider the patient’s perspective. This could imply that students who prioritise critical-thinking may place less emphasis on patient-centred aspects of clinical decision-making. The fact that critical thinking is generally associated more with analytic reasoning from evidence-based data⁴⁵ rather than decision-making guided by interpersonal interactions⁴⁶ may partly support our finding. Students who value critical thinking may rely on analysis of evidence-based data and overlook incorporating patients’ perspectives into their decisions. However, we found no other studies on the relationship between critical thinking and patient-centeredness to corroborate these findings.

Students who prioritised capability, professionalism and safety values were more inclined to consider situational factors (health-care practitioner self-awareness, service cost). Students who prioritise these values tend to reflect more on their own values, competence and cost of health-care services than other students, which is likely to improve the quality of their decisions. Clinicians who are aware of their own values and limits of competency can reflect on these issues to enable them to consider all relevant information and perspectives in their clinical decisions.¹⁰ Furthermore, clinicians have a responsibility to manage health-care resources, and their awareness of clinical costs can improve equitable distribution of health care.⁴⁷

We observed some significant differences in authority and morality value priorities between students who considered different factors in their decisions, but could not draw consistent patterns for these differences across our data. Some literature suggests that health-care practitioners’ authority and morality values influence their clinical decisions.⁴⁸ We found no meaningful differences in value rankings for altruism, equality, intellectual stimulation and pleasure. These values do not appear to have a significant influence on the factors students consider in clinical decision-making. Altruism and equality values are strongly promoted as essential values for students and health-care practitioners across health-care professional groups, while intellectual stimulation and pleasure are rarely recognised as relevant values in clinical practice.²⁷ It is possible that because these values are either universally promoted or universally shunned in health-care education, they hardly motivate different decision-making approaches in students. However, it is also possible that the scenarios we investigated did not adequately address these values.

While previous studies relating health-care students’ values to decision-making have used general measures for values and decision-making,^11–13 we used a published value instrument specifically designed to measure personal and professional values relevant to decision-making in health care.²⁷ We qualitatively coded text responses to identify factors students considered in clinical decision-making. We achieved a high agreement between two raters on the factors identified, indicating the robustness of our approach. However, the number of scenarios and therefore the range of clinical contexts we investigated was small. This may limit our ability to generalise our findings beyond clinical contexts similar to those used in this study.

Our curriculum emphasises both evidence-based and patient-centred decision-making as they apply to different contexts. Nevertheless, we found evidence that students may be inclined to use clinical evidence more, or patient-centredness more, depending on their value priorities.

We acknowledge the limitations in our study; the limited clinical experience of students and that our findings could vary with experienced health-care practitioners; the limited generalisation of our findings to other schools and cultures because of variations in curricula and value preferences across schools and cultures; and our modest response rate (49%). However, we believe our sample was representative of the class because all students had an opportunity to participate.

Overall, our findings suggest that medical students who prioritise values differently consider different factors when making decisions about patient care. The students are more or less likely to consider or ignore some factors in decision-making in different contexts depending on their value priorities. This is congruent with decision theories that suggest that the choice of factors considered in any given problem partly depends on the decision-maker’s personal characteristics and values.^49–51 Therefore, improving medical students’ and clinicians’ awareness of the influence of specific values on their clinical decisions can help them recognise and potentially moderate their personal biases to consider all relevant factors in a given clinical situation, to make informed high-quality decisions on patient care. This is an area for future research. Finally, educators can exploit the knowledge we present on explicit relations between values and factors in decision-making to enhance teaching strategies on clinical decision-making.

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