Educational programs to teach shared decision making to medical trainees: A systematic review

ObjectiveShared decision-making (SDM) is a process of collaboration between patients and clinicians. An increasing number of educational programs to teach SDM have been developed. We aimed to summarize and evaluate the body of evidence assessing the outcomes of these programs.MethodsWe conducted a systematic review of studies that aimed to teach SDM to medical trainees. Reviewers worked independently and in duplicate to select studies, extract data and evaluate the risk of bias.ResultsEighteen studies were included. Most studies focused on residents/fellows (61 %) and combined a didactic component with a practical experience (50 % used a standardized patient). Overall, participants reported satisfaction with the courses. The effects on knowledge, attitudes/confidence and comfort with SDM were small; no clear improvement on SDM skills was noted. Evaluation of clinical behavior and outcomes was limited (3/18 studies). Studies had moderate risk of bias.ConclusionVery low quality evidence suggests that educational programs for teaching SDM to medical trainees are viewed as satisfactory and have a small impact on knowledge and comfort with SDM. Their impact on clinical skills, behaviors and patient outcomes is less clear.Practical implicationsIntegration of formal and systematic outcomes evaluation (effects on behavior/clinical practice) should be part of future programs.     

Keeping the patient in the center: Common challenges in the practice of shared decision making

Objective

To examine situations where shared decision making (SDM) in practice does not achieve the goal of a patient-centered decision.

Understanding patient perceptions of shared decision making

Objective

This study aims to develop a conceptual model of patient-defined SDM, and understand what leads patients to label a specific, decision-making process as shared.

Methods

Qualitative interviews were conducted with 23 primary care patients following a recent appointment. Patients were asked about the meaning of SDM and about specific decisions that they labeled as shared. Interviews were coded using qualitative content analysis.

Results

Patients’ conceptual definition of SDM included four components of an interactive exchange prior to making the decision: both doctor and patient share information, both are open-minded and respectful, patient self-advocacy, and a personalized physician recommendation. Additionally, a long-term trusting relationship helps foster SDM. In contrast, when asked about a specific decision labeled as shared, patients described a range of interactions with the only commonality being that the two parties came to a mutually agreed-upon decision.

Conclusion

There is no one-size-fits all process that leads patients to label a decision as shared. Rather, the outcome of “agreement” may be more important than the actual decision-making process for patients to label a decision as shared.

Practice implications

Studies are needed to better understand how longitudinal communication between patient and physicians and patient self-advocacy behaviors affect patient perceptions of SDM.     

The impact and utility of encounter patient decision aids: Systematic review,meta-analysis and narrative synthesis

Objective

To determine the effect of encounter patient decision aids (PDAs) as evaluated in randomized controlled trials (RCTs) and conduct a narrative synthesis of non-randomized studies assessing feasibility, utility and their integration into clinical workflows.

Development and field testing of a decision support tool to facilitate shared decision making in contraceptive counseling

ObjectiveWe developed and formatively evaluated a tablet-based decision support tool for use by women prior to a contraceptive counseling visit to help them engage in shared decision making regarding method selection.MethodsDrawing upon formative work around women’s preferences for contraceptive counseling and conceptual understanding of health care decision making, we iteratively developed a storyboard and then digital prototypes, based on best practices for decision support tool development. Pilot testing using both quantitative and qualitative data and cognitive testing was conducted. We obtained feedback from patient and provider advisory groups throughout the development process.ResultsNinety-six percent of women who used the tool in pilot testing reported that it helped them choose a method, and qualitative interviews indicated acceptability of the tool’s content and presentation. Compared to the control group, women who used the tool demonstrated trends toward increased likelihood of complete satisfaction with their method. Participant responses to cognitive testing were used in tool refinement.ConclusionOur decision support tool appears acceptable to women in the family planning setting.Practice implicationsFormative evaluation of the tool supports its utility among patients making contraceptive decisions, which can be further evaluated in a randomized controlled trial.     

Developing a dyadic OPTION scale to measure perceptions of shared decision making

Objective

Our aim was to develop a measurement which enables research into the interdependent nature of clinical encounters. The prime objective was to develop an instrument capable of assessing the extent to which patients have been involved in (shared) decision making from two viewpoints—that of the patient and the clinician.

Methods

To develop an initial ‘dyadic OPTION’ instrument, the twelve original third-person items were drafted in passive, first person plural forms. Using this version initially, three rounds of cognitive debriefing interviews were held. These were audio-recorded and analysed at the end of each round and the results used to revise the dyadic OPTION scale.

Results

It was possible to modify the observer OPTION instrument into an instrument for completion by both clinicians and patients after a dyadic interaction. Cognitive debriefing revealed five areas of interpretative difficulty. Each item of the observer OPTION scale underwent modification in order to develop a dyadic version of the scale.

Conclusions

The dyadic OPTION scale is acceptable and comprehensible by both clinicians and public respondents. Cognitive debriefing adapted and refined an existing scale and provided confidence that the core constructs of the scale (perceived involvement in decisions making) were understood.

Practice implications

Further validation of the dyadic OPTION scale is required prior to its use in research settings.     

Measuring critical deficits in shared decision making before elective surgery

Objective

Identifying patient factors correlated with specific needs in preoperative decision making is of clinical and ethical importance. We examined patterns and predictors of deficiencies in informed surgical consent and shared decision-making in preoperative patients.

Methods

Validated measures were used to survey 1034 preoperative patients in the preoperative clinic after signed informed consent. Principal component analysis defined correlated groupings of factors. Multivariable analysis assessed patient factors associated with resultant groupings.

Results

13% of patients exhibited deficits in their informed consent process; 33% exhibited other types of deficits. Informed consent deficits included not knowing the procedure being performed or risks and benefits. Other deficits included not having addressed patient values, preferences and goals. Non-English language and lower educational level were factors correlated with higher risk for deficits.

Conclusion

Deficits exist in over a third of patients undergoing preoperative decision-making. Sociodemographic factors such as language and educational level identified particularly vulnerable groups at risk for having an incomplete, and possibly ineffective, decision-making process.

Practice implications

Interventions to identify vulnerable groups and address patient centered surgical decision making in the pre-operative setting are needed. Focused interventions to address the needs of at-risk patients have potential to improve the surgical decision-making process and reduce disparities.     

Physicians’ reactions to uncertainty in the context of shared decision making

Objective

Physicians’ reactions towards uncertainty may influence their willingness to engage in shared decision making (SDM). This study aimed to identify variables associated with physician's anxiety from uncertainty and reluctance to disclose uncertainty to patients.

Methods

We conducted a cross-sectional secondary analysis of longitudinal data of an implementation study of SDM among primary care professionals (n = 122). Outcomes were anxiety from uncertainty and reluctance to disclose uncertainty to patients. Hypothesized factors that would be associated with outcomes included attitude, social norm, perceived behavioral control, intention to implement SDM in practice, and socio-demographics. Stepwise linear regression was used to identify predictors of anxiety from uncertainty and reluctance to disclose uncertainty to patients.

Results

In multivariate analyses, anxiety from uncertainty was influenced by female gender (β = 0.483; p = 0.0039), residency status (1st year: β = 0.600; p = 0.001; 2nd year: β = 0.972; p < 0.001), and number of hours worked per week (β = −0.012; p = 0.048). Reluctance to disclose uncertainty to patients was influenced by having more years in formal education (β = −1.996; p = 0.012).

Conclusion

Variables associated with anxiety from uncertainty differ from those associated with reluctance to disclose uncertainty to patients.

Practice implications

Given the importance of communicating uncertainty during SDM, measuring physicians’ reactions to uncertainty is essential in SDM implementation studies.     

An integrative model of shared decision making in medical encounters

OBJECTIVE: Given the fluidity with which the term shared decision making (SDM) is used in teaching, assessment and research, we conducted a focused and systematic review of articles that specifically address SDM to determine the range of conceptual definitions. METHODS: In April 2005, we ran a Pubmed (Medline) search to identify articles published through 31 December 2003 with the words shared decision making in the title or abstract. The search yielded 681 citations, 342 of which were about SDM in the context of physician-patient encounters and published in English. We read and reviewed the full text of all 342 articles, and got any non-redundant references to SDM, which yielded an additional 76 articles. RESULTS: Of the 418 articles examined, 161 (38.5%) had a conceptual definition of SDM. We identified 31 separate concepts used to explicate SDM, but only "patient values/preferences" (67.1%) and "options" (50.9%) appeared in more than half the 161 definitions. Relatively few articles explicitly recognized and integrated previous work. CONCLUSION: Our review reveals that there is no shared definition of SDM. We propose a definition that integrates the extant literature base and outlines essential elements that must be present for patients and providers to engage in the process of SDM. PRACTICE IMPLICATIONS: The integrative definition of SDM is intended to provide a useful foundation for describing and operationalizing SDM in further research.     

Remote shared decision making through telemedicine: A systematic review of the literature

ObjectivesTo assess the extent to which shared decision making (SDM) can take place in telemedicine (remote SDM).MethodsWe searched Medline, Cochrane, and Scopus from 2010 until August 7th, 2020 for articles on remote SDM in the care of any patient using any technology. We also conducted a search for telemedicine articles citing key reports on SDM outcome measures. Two reviewers independently screened titles and abstracts, reviewed full text eligible studies, and synthesized their content using thematic analysis.ResultsOf the 12 eligible articles, most were European with patients with chronic disease or mental and behavioral health. 8 articles used synchronous remote SDM and 1 used asynchronous remote SDM. Themes related to interactional workability of both telemedicine technologies and SDM emerged, namely access to broadband, digital literacy, and satisfaction with the convenience of remote visits.ConclusionsTelemedicine technologies may foster virtual interactions that support remote SDM, which, in turn, may promote productive patient-clinician interactions and patient-centered care.Practice implicationsDigitally-mediated consultations surged amidst the COVID-19 pandemic. The extent to which SDM frameworks developed for in-person use need any adaptation for remote SDM remains unclear. Investment in innovation, design, implementation, and effectiveness research to advance remote SDM are needed.     

Text-only and picture conversation aids both supported shared decision making for breast cancer surgery: Analysis from a cluster randomized trial

ObjectivesTo determine if two encounter conversation aids for early-stage breast cancer surgery increased observed and patient-reported shared decision making (SDM) compared with usual care and if observed and patient-reported SDM were associated.MethodsSurgeons in a cluster randomized trial at four cancer centers were randomized to use an Option Grid, Picture Option Grid, or usual care. We used bivariate statistics, linear regression, and multilevel models to evaluate the influence of trial arm, patient socioeconomic status and health literacy on observed SDM (via OPTION-5) and patient-reported SDM (via collaboRATE).ResultsFrom 311 recordings, OPTION-5 scores were 73/100 for Option Grid (n = 40), 56.3/100 for Picture Option Grid (n = 144), and 41.0/100 for usual care (n = 127; p < 0.0001). Top collaboRATE scores were 81.6 % for Option Grid, 80.0 % for Picture Option Grid, and 56.4 % for usual care (p < 0.001). Top collaboRATE scores correlated with an 8.60 point (95 %CI 0.66, 13.7) higher OPTION-5 score (p = 0.008) with no correlation in the multilevel analysis. Patients of lower socioeconomic status had lower OPTION-5 scores before accounting for clustering.ConclusionsBoth conversation aids led to meaningfully higher observed and patient-reported SDM. Observed and patient-reported SDM were not strongly correlated.Practice implicationsHealthcare providers could implement these conversation aids in real-world settings.     

Promoting shared decision making in advanced cancer: Development and piloting of a patient communication aid

Objective

To learn how to configure a patient communication aid (PCA) to facilitate shared decision-making (SDM) about treatment for advanced cancer.

General practitioners' views on shared decision making: a qualitative analysis

Despite rhetoric about increasing partnership in the consultation, shared decision making (SDM) is not necessarily happening in practice. As patient involvement in decision making cannot be achieved without general practitioners’ (GPs) co-operation, attention to their concerns is essential. Previous research has used simulated patients to explore this area. Here, data from consultations and interviews with patients and GPs were used in focus group discussions enabling GPs to ground their views of the practical application of SDM in their own and other participants’ real life practice. The following ideas were discussed; what constitutes SDM in practice, negotiation about treatment, perceptions of patients’ viewpoints and perceived barriers to SDM. Agreement with SDM in theory may not translate into practice. The process outlined is being developed in order to establish whether the techniques could provide a supportive environment in which GPs can make changes to their practice to increase patient participation.     

Factors associated with level of shared decision making in Malaysian primary care consultations

ObjectiveTo measure the level of shared decision-making (SDM) in primary care consultations in Malaysia, a multicultural, middle-income developing country.MethodsA cross-sectional study was conducted in an urban, public primary care clinic. Convenience sampling was used to recruit participants, and audio-recorded consultations were scored for SDM levels by two independent raters using the OPTION tool. Univariate and multivariate analysis was conducted to determine factors significantly associated with SDM levels.Results199 patients and 31 doctors participated. Mean consultation time was 14.3 min (+ SD 5.75). Patients’ age ranged from 18 to 87 years (median age of 57.5 years). 52.8 % of patients were female, with three main ethnicities (Malay, Chinese, Indian). The mean OPTION score was found to be 7.8 (+ SD 3.31) out of 48. After a multivariate analysis, only patient ethnicity (β= -0.142, p < 0.05) and increased consultation time (β = 0.407, p < 0.01) were associated with higher OPTION scores.ConclusionsPatients in Malaysia experience extremely poor levels of SDM in general practice. Higher scores were associated with increased consultation time and patient ethnicity.Practice implicationsMalaysian general practitioners should aim to develop and practice cultural competency skills to avoid biased SDM practice towards certain ethnicities.     

Cultural challenges to engaging patients in shared decision making

ObjectiveEngaging patients in their health care through shared decision-making is a priority embraced by several national and international groups. Missing from these initiatives is an understanding of the challenges involved in engaging patients from diverse backgrounds in shared decision-making. In this commentary, we summarize some of the challenges and pose points for consideration regarding how to move toward more culturally appropriate shared decision-making.DiscussionThe past decade has seen repeated calls for health policies, research projects and interventions that more actively include patients in decision making. Yet research has shown that patients from different racial/ethnic and cultural backgrounds appraise their decision making process less positively than do white, U.S.-born patients who are the current demographic majority.ConclusionWhile preliminary conceptual frameworks have been proposed for considering the role of race/ethnicity and culture in healthcare utilization, we maintain that more foundational and empirical work is necessary. We offer recommendations for how to best involve patients early in treatment and how to maximize decision making in the way most meaningful to patients. Innovative and sustained efforts are needed to educate and train providers to communicate effectively in engaging patients in informed, shared decision-making and to provide culturally competent health care.     

Patient-important outcomes to inform shared decision making and goal setting for diabetes treatment

ObjectiveDespite well-established treatment guidelines, diabetes is difficult to manage for many individuals. The importance of using shared decision making to optimize diabetes treatment is recognized, yet what matters most to individuals with diabetes is not well established. Our goal was to identify patients’ goals and priorities for diabetes management.MethodsWe engaged 141 participants through interviews and group concept mapping to identify patient-important outcomes (PIOs) for diabetes care. We generated a master list of PIOs by aggregating interview data coded to “goals” and ideas brainstormed during concept mapping, and then a patient advisory board sorted the PIOs into higher-level domains.ResultsWe identified 41 PIOs sorted into 7 broad domains: optimize daily self-care, optimize long term health, learn about diabetes, achieve measurable goals, manage medications, manage diet and best utilize medical / professional services.ConclusionsMost (4/7) of PIO domains focused on personal and life goals, not medically-oriented goals. Use of these PIOs and domains may facilitate more effective SDM discussions for patients with diabetes.Practice implicationsUse of PIOs from this work can enable the empowerment of patients to voice their priorities during SDM conversations, thus facilitating development of truly individualized diabetes treatment plans.