Competing norms:: Canadian rural family physicians' perceptions of clinical practice guidelines and shared decision-making

Objectives: Implementation of clinical practice guidelines (CPGs) and shared decision-making are both advocated in primary care. Some authors argue that CPGs can enhance informed decisions by patients and physicians, while others warn that a standardized implementation of CPGs could hinder patients' involvement in decision.-making. Our objective was to explore rural family physicians' perception of the interaction between clinical practice guidelines and shared decision-making in medical practice. Methods: A qualitative study using a semi-structured focus group interview: with 17 family physicians and residents, in a Canadian rural town. Interviews were audio-taped and transcribed verbatim. Thematic content analysis was: performed and validated by the constant comparative method, member checking and group debriefing. Results: Two distinct conceptions of how clinical practice guidelines should assist decision-making emerged. On the one hand, guidelines were seen as helping clinicians to make decisions on behalf of their patient about the best course of action. For interventions with uncertain benefit or that carried significant trade-off for patients, guidelines were seen as a tool that should inform decision-making between physicians and patients, providing them with details about risks, benefits, costs and alternative treatments. The pressure to apply guideline recommendations was perceived as a potential barrier to patient participation in decision-making. Conclusion: In circumstances where physicians judge patient participation in decision-making to be important, physicians perceive a tension between the need to respect patients' preferences and the pressure to apply guidelines. CPGs should include information that supports shared decision-making, besides their current focus on influencing prescription patterns, costs and health outcomes.