Challenges of implementing collaborative models of decision making with trans‐identified patients

Background

Factors health providers face during the doctor–patient encounter both impede and assist the development of collaborative models of treatment.

Objective

I investigated decision making among medical and therapeutic professionals who work with trans‐identified patients to understand factors that might impede or facilitate the adoption of the collaborative decision‐making model in their clinical work.

Design

Following a grounded theory approach, I collected and analysed data from semi‐structured interviews with 10 U.S. physicians and 10 U.S. mental health professionals.

Results

Doctors and therapists often desire collaboration with their patients but experience dilemmas in treating the trans‐identified patients. Dilemmas include lack of formal education, little to no institutional support and inconsistent understanding and application of the main documents used by professionals treating trans‐patients.

Conclusions

Providers face considerable risk in providing unconventional treatments due to the lack of institutional and academic support relating to the treatment for trans‐people, and the varied interpretation and application of the diagnostic and treatment documents used in treating trans‐people. To address this risk, the relationship with the patient becomes crucial. However, trust, a component required for collaboration, is thwarted when the patients feel obliged to present in ways aligned with these documents in order to receive desired treatments. When trust cannot be established, medical and mental health providers can and do delay or deny treatments, resulting in the imbalance of power between patient and provider. The documents created to assist in treatment actually thwart professional desire to work collaboratively with patients.     

‘Too much for one day’: a case study of disclosure in the paediatric HIV/AIDS clinic

Background

Despite acknowledgement of the complexity and challenges of the process of disclosure of HIV status to adolescents, little work has been carried out on the communication features which facilitate or hinder the process. This qualitative case study reflects the interactional dynamics of an interaction between caregiver, physician and counsellor around the topic of disclosure in a South African clinic.

Methods

A 40‐minute encounter between a doctor, the grandmother of an adolescent with HIV/AIDS and a counsellor around the process of disclosure was transcribed and examined in detail in relation to its structure, topics, timing and sequence as well as its movement towards a collaborative ending. Analysis was based on elements of conversational and thematic analysis.

Results

The session was characterized by distinct stages and the emergence of multiple voices and perspectives from the participants. The negotiated management of the session sheds light on multiple barriers to care as well as the influence of contextual factors on the process. The important mediating role of the counsellor in the triad emerges. The analysis highlights both unique features of the consultation and common challenges to clinicians when disclosing.

Discussion and Conclusions

The task of disclosure is complex and intricate. Results suggest team processes are critical, as are temporal and contextual factors and the need for an understanding of communication. Implications for the clinic team are discussed and suggestions made for the development of collaborative partnership based on an understanding of roles and responsibilities, time factors and enhancement of features such as trust and communication.