Medical Students' Attitudes and Experiences Regarding Persuasion of Patients by Physicians: Clarifying the Ethics of Shared Decision Making.

Background: Ethical principles of autonomy and beneficence guide clinical decision making. Little is known about how clinicians prioritize these principles and integrate them with virtue ethics when assessing the ethics of persuasion.

Objective: Survey medical students about their attitudes and experiences regarding the use of persuasion by physicians in shared decision making.

Design: Cross-sectional, on-line survey.

Participants: Pre-clinical and clinical medical students at one US medical school.

Main measures: Survey instrument contained 31 items including a three-part clinical vignette, attitudes toward persuasion and ethical principles, experiences observing or participating in persuasion, and demographic information. Bivariate and multivariable analyses were performed, including LASSO regression using a 30-point persuasion score derived from six items.

Key results: 237 students completed the survey (45% response rate). In general, 55.7% supported persuasion by physicians for the good of the patient's health. Nearly half supported persuasion for an at-risk cardiovascular patient who declines recommendations for walking or statin treatment; 64.1% supported persuasion for a patient with myocardial infarction who wants to leave the hospital against medical advice. While 70.0% believed persuasion is appropriate because it promotes beneficence and nonmaleficence, 16.9% believed persuasion is inappropriate because it disrespects patient autonomy. Most students (81.0%) had seen a good physician role model for persuasion, and 38.0% had willingly participated in persuasion. LASSO regression identified four items contributing positively to the persuasion score (belief that persuasion promotes beneficence/nonmaleficence, observation of a good role model, experience participating in persuasion, male gender) and two negatively (belief that persuasion disrespects patient autonomy, observation of inappropriate use of persuasion).

Conclusions: Medical students vary in attitudes toward persuasion of patients by physicians, and variations are associated with differences in ethical beliefs, clinical experiences, and gender. Education regarding the use of persuasion should address ethical justification, experience, and role-modeling-which can be encompassed by virtue ethics.