Objective: There is little academic literature describing the nature of pre-surgical visits. To address this dearth and informed by a patient-centered approach, this dissertation examined the dynamics of the pre-surgical encounter. Methods: Based on secondary analysis of presurgical recordings with 61 patients and eight surgeons. Patients were recruited at nine surgical oncology clinics at an academic hospital from July 2015-September 2016. First, I described the human-centered design (HCD) process used to develop an advance care planning decision support video aimed to enhance the patient-centeredness of the pre-surgical encounter. Second, I quantitatively explored how companions modify surgeons’ and patients’ contributions. Poisson and logistic regression models were used to assess differences in in accompanied vs. unaccompanied visits regarding communication, as captured by the Roter Interaction Analysis System, and satisfaction. Models were fit using generalized estimating equations. Finally, I qualitatively examined case studies of how shared decision making manifests in the context of an unexpected decision in this encounter. Results: First, over 450 stakeholders contributed to setting objectives, applying for funding, and providing feedback on the storyboard and the video. Opinions were compiled and conflicting approaches negotiated resulting in a tool that satisfied stakeholders. Second, companion presence was associated with a 29% increase in surgeon talk in the visit overall (IRR 1.29, p=0.006), and a 41% increase in the amount of medical information provided (IRR 1.41, p=0.001). Companion presence was associated with 45% less patient disclosure related to lifestyle/psychosocial topics (IRR 0.55, p=0.037). In adjusted analyses, companions’ presence was associated with 23% lower levels of patient-centeredness (IRR 0.77, p 0.004). Finally, four presurgical visits were identified as having a disruption. Each case study explores the disruption, participants’ reactions to and resolution of the disruption. Cross-cutting themes include companions’ patient autonomy-enhancing and detracting behaviors, and surgeons’ collaborative, facilitative, and informative behaviors. Conclusions: By improving our understanding of these visits, we can better prepare patients, their companions, and surgeons for these encounters, and ideally make these encounters more patient-centered. As this is the first study to explore in-depth the nature of these presurgical conversations, further analyses are required with a more diverse population.
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