Identifying residents’ educational needs to optimising postgraduate medical education about shared decision-making

ObjectiveTo investigate how to optimise resident engagement during workplace learning of shared decision-making (SDM) by understanding their educational needs.MethodsA qualitative multicentre study was conducted using video-stimulated interviews with 17 residents in General Practice. Video recordings of residents’ recent clinical encounters were used to facilitate reflection on their educational needs.ResultsData analysis resulted in five themes regarding residents’ educational needs for learning SDM: acquiring knowledge and skills needed to perform SDM; practising SDM; reflection and feedback; longitudinal and integrated training; and awareness and motivation for performing SDM.ConclusionResidents expressed a need for continuous attention to be paid to SDM during postgraduate medical education. That would help them engage in two parallel learning processes: acquiring the knowledge and skills necessary to perform SDM, and practising SDM in the clinical workplace. Alignment between the educational curriculum, workplace learning and resident learning activities is essential to operationalise SDM attitude, knowledge and skills into clinical performance.Practice ImplicationsThe identified educational needs provide ingredients for fostering the development of SDM proficiency. The findings suggest that residents and clinical supervisors need parallel training to bridge the gap between education and clinical practice when learning SDM.     

Shared decision-making and outcomes in type 2 diabetes: A systematic review and meta-analysis

ObjectiveType 2 diabetes is a chronic disease which necessitates the development of a therapeutic alliance between patient and provider. This review systematically examines the association between treatment shared decision-making (SDM) and outcomes in diabetes.MethodsA range of bibliographic databases and gray literature sources was searched. Included studies were subjected to dual data extraction and quality assessment. Outcomes were synthesized using meta-analyses where reporting was sufficiently homogenous or alternatively synthesized in narrative fashion.ResultsThe search retrieved 4592 records, which were screened by title, abstract, and full text to identify 16 studies with a range of study designs and populations. We found evidence of an association between SDM and improved decision quality, patient knowledge and patient risk perception. We found little evidence of an association between SDM and glycemic control, patient satisfaction, quality of life, medication adherence or trust in physician.ConclusionsThis work elucidates the potential clinical utility of SDM interventions in the management of Type 2 Diabetes and helps inform future research on the topic.Practice implicationsA more complete understanding of the associations between SDM and outcomes will guide and motivate efforts aimed at improving uptake of the SDM paradigm.     

Teaching medical students how to deliver diagnoses of Down syndrome: Utility of an educational tool

ObjectiveThis study assessed whether using an educational tool increased the knowledge and perceived comfort level of first-year medical students in giving a diagnosis of Down syndrome.MethodA total of 295 students taking a genetics course completed a knowledge questionnaire and Situations Inventory (aimed at assessing comfort with sharing certain information), prior to and following use of Brighter Tomorrows, a web-based educational module on giving parents a diagnosis of Down syndrome.ResultsThe pre-intervention mean on the knowledge survey was 3.67, which significantly increased to 5.47 following the intervention. Mean Situational Inventory scores were significantly higher pre-intervention (M = 45.5), which indicates greater discomfort, compared to post-intervention (M = 36.7). Qualitative analysis of responses regarding lessons learned fell into 5 major themes. The most common theme (48% of responses) was related to communication skills. The most frequently cited lesson learned was the importance of demonstrating empathy.ConclusionsThis study found that knowledge and perceived comfort levels of first-year medical students in giving a postnatal diagnosis of Down syndrome were significantly increased following use of an educational tool.Practice ImplicationsEducational modules can provide medical students with foundational knowledge on providing distressing information to help prepare for future clinical encounters.     

What makes a patient ready for Shared Decision Making? A qualitative study

ObjectivesShared decision making (SDM) requires an active role from patients, which might be difficult for some. We aimed to identify what patients need to be ready (i.e., well-equipped and enabled) to participate in SDM about treatment, and what patient- and decision-related characteristics may influence readiness.MethodsWe conducted semi-structured interviews with patients and professionals (physicians, nurses, general practitioners, and researchers). Interviews were analyzed inductively.ResultsWe identified five elements of patient readiness: 1) understanding of and attitude towards SDM, 2) health literacy, 3) skills in communicating and claiming space, 4) self-awareness, and 5) consideration skills. We identified 10 characteristics that may influence elements of readiness: 1) age, 2) cultural background, 3) educational background, 4) close relationships, 5) mental illness, 6) emotional distress, 7) acceptance of diagnosis, 8) clinician-patient relationship, 9) decision type, and 10) time.ConclusionsWe identified a wide range of elements that may constitute patient readiness for SDM. Readiness might vary between and within patients. This variation may result from differences in patient- and decision-related characteristics.Practice implicationsClinicians should be aware that not all patients may be ready for SDM at a given moment and may need support to enhance their readiness.     

A shared decision-making communications workshop improves internal medicine resident skill,risk-benefit education,and counseling attitude

ObjectiveWe assessed the impact of a workshop on first-year medicine residents (PGY1) shared decision-making (SDM) communication skill, risk-benefit education, and attitude.MethodsA SDM skills-focused workshop was integrated into an academic medical center PGY1 ambulatory rotation in 2016–2017. Pre/post recordings of virtual Objective Structured Clinical Examinations (OSCEs) with standardized patients sharing decisions were scored using OPTION5. Risk-benefit education, including decision aid use, was measured. Pre/post surveys assessed SDM practice attitudes and perceived barriers.Results31 of 48 (65%) PGY1 workshop attendees completed pre/post OSCEs yielding 62 videos. OPTION5 scores improved from 27/100 pre to 56/100 post (p < 0.001). Pre/post increases in integration of qualitative (15/31 vs 31/31, p < 0.001) and quantitative (3/31 vs 31/31, p < 0.001) risk measures, and decision aids (1/3 vs 31/31, p < 0.001) were observed. Pro-SDM attitude of decisional neutrality increased 16.6% pre to 71.9% post-survey (P < 0.001). Barriers to SDM remain.ConclusionThis PGY1 workshop with virtual OSCEs improved SDM communication skills, the ability to find and provide risk-benefit education, and SDM-facilitating attitude.Practice implicationsResidency programs can improve SDM skills, risk-benefit education, and attitudes with a workshop intervention. Perceived time constraints and cognitive biases regarding risk-benefit estimates should be addressed to ensure quality SDM in practice.     

Using incorpoRATE to examine clinician willingness to engage in shared decision making: A study of Family Medicine residents

ObjectivesWe evaluated the willingness of Family Medicine residents to engage in SDM, before and after an educational intervention.MethodsWe delivered a lecture and a workshop for residents on implementing SDM in preventive health care. Before the lecture (T1), participants completed a measure of their willingness to engage in SDM. Six months later, participants completed the measure a second time (T2).ResultsAt T1, 64 of 73 residents who attended the educational session completed incorpoRATE. Six months later, 44 of 64 participants completed the measure a second time (T2). The range of incorpoRATE sum scores at T1 was from 4.9 to 9.1 out of 10. Among the 44 participants who completed incorpoRATE at both time points, the mean scores were 7.0 ± 1.0 at T1 and 7.4 ± 1.0 at T2 (t = ?2.833, p = 0.007, Cohen’s D = 0.43).ConclusionAmong Family Medicine residents, the willingness to engage in SDM is highly variable. This suggests a lack of consensus in the mind of these residents about SDM. Although mean scores at T2 were significantly higher, we question the educational importance of this change.Practice implicationsincorpoRATE is a promising measure for educators. Understanding how willing a particular physician audience is to undertake SDM, and which elements require attention, could be helpful in designing more targeted curricula. Further research is needed to understand how the perceived stakes of a clinical situation influence physician willingness to engage in SDM.     

Bringing personal perspective elicitation to the heart of shared decision-making: A scoping review

ObjectivesProponents of shared decision-making (SDM) advocate the elicitation of the patient’s perspective. This scoping review explores if, and to what extent, the personal perspectives of patients are elicited during a clinical encounter, as part of a SDM process. We define personal perspective elicitation (PPE) as: the disclosure (either elicited by the clinician or spontaneously expressed by the patient) of information related to the patient’s personal preferences, values and/or context.MethodsA search was conducted in five literature databases from inception dates up to July 2020, to identify empirical studies about SDM (with/without SDM instrument).ResultsThe search identified 4562 abstracts; 263 articles were read in full text, resulting in 99 included studies. Studies reported low levels of PPE. Integration of personal perspectives into the conversation or a future care plan was largely absent. The majority of the discussed content related to physical health, while social and psychological topics were mostly unaddressed.ConclusionsPPE occurs on a very low level in efforts to achieve SDM according to evaluation studies.Practice implicationsPPE is advocated but rarely achieved in SDM evaluation studies. Causes should be identified, followed by designing interventions to improve this aspect of SDM.     

Genetics/genomics education for nongenetic health professionals: a systematic literature review

PurposeThe completion of the Human Genome Project has enhanced avenues for disease prevention, diagnosis, and management. Owing to the shortage of genetic professionals, genetics/genomics training has been provided to nongenetic health professionals for years to establish their genomic competencies. We conducted a systematic literature review to summarize and evaluate the existing genetics/genomics education programs for nongenetic health professionals.MethodsFive electronic databases were searched from January 1990 to June 2016.ResultsForty-four studies met our inclusion criteria. There was a growing publication trend. Program participants were mainly physicians and nurses. The curricula, which were most commonly provided face to face, included basic genetics; applied genetics/genomics; ethical, legal, and social implications of genetics/genomics; and/or genomic competencies/recommendations in particular professional fields. Only one-third of the curricula were theory-based. The majority of studies adopted a pre-/post-test design and lacked follow-up data collection. Nearly all studies reported participants’ improvements in one or more of the following areas: knowledge, attitudes, skills, intention, self-efficacy, comfort level, and practice. However, most studies did not report participants’ age, ethnicity, years of clinical practice, data validity, and data reliability.ConclusionMany genetics/genomics education programs for nongenetic health professionals exist. Nevertheless, enhancement in methodological quality is needed to strengthen education initiatives.Genet Med advance online publication 20 October 2016     

Making shared decisions in relation to planned caesarean sections: What are we up to?

ObjectiveTo map the literature in relation to shared decision making (SDM) for planned caesarean section (CS), particularly women’s experiences in receiving the information they need to make informed decisions, their knowledge of the risks and benefits of CS, the experiences and attitudes of clinicians in relation to SDM, and interventions that support women to make informed decisions.MethodsUsing a scoping review methodology, quantitative and qualitative evidence was systematically considered. To identify studies, PubMed, Maternity and Infant Care, MEDLINE, and Web of Science were searched for the period from 2008 to 2018.Results34 studies were included, with 9750 women and 3313 clinicians. Overall women reported limited SDM, and many did not have the information required to make informed decisions. Clinicians generally agreed with SDM, while recognising it often does not occur. Decision aids and educational interventions were viewed positively by women.ConclusionMany women were not actively involved in decision-making. Decision aids show promise as a SDM-enhancing tool. Studies that included clinicians suggest uncertainty regarding SDM, although willingness to engage.Practice implications: Moving from clinician-led decision-making to SDM for CS has potential to improve patient experiences, however this will require considerable clinician training, and implementation of SDM interventions.     

Systematic review of outcomes in studies of reproductive genetic carrier screening: Towards development of a core outcome set

PurposeCurrent practice recommendations support the widespread implementation of reproductive genetic carrier screening (RGCS). These consensus-based recommendations highlight a research gap, with findings from current studies being insufficient to meet the standard required for more rigorous evidence-based recommendations. This systematic review assessed methodological aspects of studies on RGCS to inform the need for a core outcome set.MethodsWe conducted a systematic search to identify peer-reviewed published studies offering population-based RGCS. Study designs, outcomes, and measurement methods were extracted. A narrative synthesis was conducting using an existing outcome taxonomy and criteria used in the evaluation of genetic screening programs as frameworks.ResultsSixty-five publications were included. We extracted 120 outcomes representing 24 outcome domains. Heterogeneity in outcome selection, measurement methods and time points of assessment was extensive. Quality appraisal raised concerns for bias. We found that reported outcomes had limited applicability to criteria used to evaluate genetic screening programs.ConclusionDespite a large body of literature, diverse approaches to research have limited the conclusions that can be cumulatively drawn from this body of evidence. Consensus regarding meaningful outcomes for evaluation of RGCS would be a valuable first step in working towards evidence-based practice recommendations, supporting the development of a core outcome set.     

Healthcare professionals’ behaviour regarding the implementation of shared decision-making in screening programmes: A systematic review

ObjectiveTo explore the barriers to and facilitators of healthcare professionals’ implementation of SDM regarding screening programmes.MethodA systematic review was conducted in PubMed, Cochrane Library, CINHAL, and PsyscInfo. The barriers and facilitators identified were classified into three factors based on their origin: patients, healthcare system performance, and healthcare professionals themselves.ResultsEight studies were selected: seven related to cancer screening. The most significant facilitators were literacy and interest in active participation, both of which have their origins in patients. The most significant barriers identified for the first time in a systematic review were legal conflict, lack of remuneration and lack of flexibility in clinical guidelines in screening programmes.ConclusionThe results of this study show that there are differences between barriers and facilitators for SDM when it is applied in the context of healthy people who perform preventive activities, particularly screening, in contrast to general medical consultation contexts.Practical implicationsThe authors suggest that to advance in the practice of SDM, we need to develop and disseminate training documents. Further, SDM should be incorporated into clinical guidelines. There should be more studies focusing on healthcare professionals’ behaviour within the context of the uncertainty of screening programmes.     

Teaching Students about Intravenous Therapy: Increased Competence and Confidence

Aim/PurposeGraduate nurses require competency in IV therapy. Associate Degree in Nursing (ADN) programs offer elective IV education to provide additional information for interested students. After instituting such a course, students' perceived comfort and knowledge of IV therapy were evaluated.Review of Relevant LiteratureStudies demonstrated that IV education for nurses in practice helped reduce complication rates. Dated research also indicated that nursing programs were reluctant to provide IV instruction that included advanced skills, such as catheter insertions. More recent literature involved teaching methodology.MethodsA researcher-designed survey was distributed at the completion of an ADN program to evaluate perceived knowledge and comfort related to IV therapy, as well as information about IV education throughout the program.ResultsStudents who participated in the workshop perceived having a higher level of comfort and knowledge of several IV content areas than those who participated in the course or had no elective IV education. Conversely, participants in the workshop and course felt more comfortable with central line dressing changes and IV insertions than students who did not take either IV educational offering.ConclusionsThe standard IV education appeared to provide adequate knowledge and comfort with IV therapy. However, optional IV education benefited students who wanted more in depth IV knowledge and skills.Implications for PracticeThe best methods for teaching ADN students about IV therapy remains unknown. However, offering an elective course provides opportunities for interested students to increase their knowledge and comfort related to IV therapy prior to graduation.     

Interventions to improve medication adherence in inflammatory bowel disease: A systematic review

ObjectiveTo summarize existing literature examining interventions to enhance medication adherence and their effectiveness in enhancing care for inflammatory bowel disease (IBD) patients.MethodsThis review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. PubMed and Embase were searched for studies from June 2014 to Dec 2020. Only the studies published in English were included.ResultsOur systematic literature search identified 488 published articles. Seventeen studies with a total of 7073 patients were included. Out of seventeen different interventions, five were classified as educational, eight as multicomponent, three as behavioral and one as cognitive behavioral. Adherence was measured using patient self-report, administrative/pharmacy claims data, and electronic monitoring devices/pill dispensing systems. Twelve out of seventeen interventions showed a statistically significant improvement in medication adherence including three educational, seven multicomponent, one behavioral and one cognitive behavioral intervention.ConclusionsMulticomponent interventions demonstrated the greatest success in IBD patients in promoting medication adherence. Future research should focus on a multidisciplinary approach to design multicomponent interventions to optimize treatment adherence and enhance long-term clinical outcomes.Practice implicationsWhile stand-alone strategies have demonstrated effectiveness in improving adherence, better outcomes may be achieved by combining multiple strategies.     

The impact of residents’ training in Electronic Medical Record (EMR) use on their competence: Report of a pragmatic trial

ObjectivesEven though Electronic Medical Records (EMRs) are increasingly used in healthcare organizations there is surprisingly little theoretical work or educational programs in this field. This study is aimed at comparing two training programs for doctor–patient–computer communication (DPCC).Methods36 Family Medicine Residents (FMRs) participated in this study. All FMRs went through twelve identical simulated encounters, six pre and six post training. The experiment group received simulation based training (SBT) while the control group received traditional lecture based training.ResultsPerformance, attitude and sense of competence of all FMRs improved, but no difference was found between the experiment and control groups. FMRs from the experiment group evaluated the contribution of the training phase higher than control group, and showed higher satisfaction.ConclusionWe assume that the mere exposure to simulation served as a learning experience and enabled deliberate practice that was more powerful than training. Because DPCC is a new field, all participants in such studies, including instructors and raters, should receive basic training of DPCC skills.Practice implicationSimulation enhances DPCC skills. Future studies of this kind should control the exposure to simulation prior to the training phase. Training and assessment of clinical communication should include EMR related skills.     

A systematic review of patient-practitioner communication interventions involving treatment decisions

ObjectivesTo examine the: 1) methodological quality of interventions examining strategies to improve patient-practitioner communication involving treatment decisions; 2) effectiveness of strategies to improve patient-practitioner communication involving treatment decisions; and 3) types of treatment decisions (emergency/non-emergency) in the included studies.MethodsMedline, PsychINFO, CINAHL, and Embase were searched to identify intervention studies. To be included, studies were required to examine patient-practitioner communication related to decision making about treatment. Study methodological quality was assessed using Cochrane’s Effective Practice and Organisation of Care risk of bias criteria. Study design, sample characteristics, intervention details, and outcomes were extracted.ResultsEleven studies met the inclusion criteria. No studies were rated low risk on all nine risk of bias criteria. Two of the three interventions aimed at changing patient behaviour, two of the five practitioner directed, and one of the three patient-practitioner directed interventions demonstrated an effect on decision-making outcomes. No studies examined emergency treatment decisions.ConclusionsExisting studies have a high risk of bias and are poorly reported. There is some evidence to suggest patient-directed interventions may be effective in improving decision-making outcomes.Practice implicationsIt is imperative that an evidence-base is developed to inform clinical practice.     

Effectiveness of multimedia interventions in the provision of patient education on anticoagulation therapy: A review

ObjectiveA literature review was conducted to identify available evidence on the use of multimedia patient educational interventions on anticoagulation therapy.MethodsA literature search was conducted on 9/4/2020 via six research databases. Publications that evaluated the effects of these interventions on anticoagulation therapy were included.ResultsThe review included ten original research studies (five randomized controlled trials, four observational studies and a pre- and post-interventional study), a systematic review and meta-analysis, three systematic reviews, a scoping review, and a literature review.Multimedia interventions significantly improved knowledge after education, but no significant differences found when compared to traditional methods. There was insufficient evidence to conclude whether knowledge retained over time. Patients were equally satisfied with both methods. Multimedia interventions significantly reduced healthcare professional’s time required for education. Heterogeneity in intervention, methodology and results limited comparison and combination of findings across studies.ConclusionMultimedia patient educational interventions on anticoagulation therapy have similar outcomes to traditional methods in knowledge improvement and satisfaction, but they save health personnel time.Practice implicationsThere is lack of evidence to support the effectiveness of multimedia interventions in educating patients on anticoagulation therapy. Larger randomized studies evaluating their benefits in health outcomes and clinical practice are warranted.     

An educational game for teaching clinical practice guidelines to Internal Medicine residents: development,feasibility and acceptability

Background  

Adherence to Clinical Practice Guidelines (CPGs) remains suboptimal among internal medicine trainees. Educational games are of growing interest and have the potential to improve adherence to CPGs. The objectives of this study were to develop an educational game to teach CPGs in Internal Medicine residency programs and to evaluate its feasibility and acceptability.