Patients’ preferred and perceived decision-making roles,and observed patient involvement in videotaped encounters with medical specialists

ObjectiveTo assess how patients prefer and perceive medical decision making, which factors are associated with their preferred and perceived decision-making roles, and whether observed involvement reflects patients’ perceived role.MethodsWe asked 781 patients visiting a medical specialist from 18 different disciplines to indicate their preferred and perceived decision-making roles. Patient involvement in videotaped consultations was assessed with the OPTION5 instrument.ResultsMost patients preferred and perceived decision making as shared (SDM; 58% and 43%, respectively), followed by paternalistic (26% and 38%), and informative (16% and 15%). A large minority (n = 103, 21%) of patients preferring shared or informative decision making (n = 482) experienced paternalistic decision making. Mean (SD) OPTION5 scores were highest in consultations which patients perceived as informative (26.0 (19.7)), followed by shared (19.1 (17.2)) and lowest in paternalistic decision making (11.8 (13.4) p < 0.001).ConclusionsMost patients want to be involved in decision making. Patients perceive that the physician makes the decision more often than they prefer, and perceive more involvement in the decision than objective assessment by an independent researcher shows.Practice implicationsA clearer understanding of patients’ medical decision-making experiences is needed to optimize physician SDM training programmes and patient awareness campaigns.     

Gender differences in the decision-making process for undergoing total knee replacement

ObjectiveTo assess gender differences in the decision-making process for treatment of knee osteoarthritis (OA).MethodsA secondary analysis of a randomized trial was conducted (n = 193). Knowledge of OA and total knee replacement (TKR), decisional conflict, satisfaction with the decision-making process, treatment preference and TKR uptake 6 months later were compared by gender. Multivariate regression models were developed to identify gender-specific predictors.ResultsWomen showed less knowledge (MD = ?7.68, 95% CI: ?13.9, ?1.46, p = 0.016), reported less satisfaction (MD = ?6.95, 95% CI: ?11.7, ?2.23, p = 0.004) and gave more importance to avoiding surgery (U = 2.09, p = 0.019). In women, more importance attributed to the time needed to relieve symptoms significantly reduced the odds of surgery (OR = 0.76, p = 0.016).ConclusionThe provision of information and/or promotion of shared decision-making could be of lower quality in female patients, although other explanations such as differences in information needs or preference for involvement in decision-making cannot be ruled out with the current evidence. Given the study’s limitations, especially regarding the sample size, further confirmation is needed.Practice implicationsA systematic, shared decision-making approach in consultation is needed to avoid potential gender-based biases.     

Active involvement of young people with T1DM during outpatient hospital consultations: Opportunities and challenges in transitional care services

ObjectiveLittle is known about active involvement of young people (YP) with type 1 diabetes (T1DM) in transitional care. This study aims to gain insight into patient-provider interactions during outpatient hospital consultations.MethodsSemi-structured observations (n = 61) of outpatient consultations with YP with T1DM (15–25 years) treated in 12 hospitals in the Netherlands. The consultations concerned pediatric care (n = 23), adult care (n = 17), and joint consultations (n = 21). Thematic data analysis focused on whether professionals engaged in open, in-depth conversations; used motivational interviewing techniques; involved YP in shared decision-making; and addressed non-medical topics.ResultsApart from some good examples, the healthcare professionals generally had difficulty interacting adequately with YP. They paid little attention to the YP’s individual attitudes and priorities regarding disease management; non-medical topics remained generally underexposed. Conversations about daily life often remained shallow, as YP’s cues were not taken up. Furthermore, decisions about personal and health-related goals were often not made together.ConclusionBy adopting a more person-centered approach, professionals could empower YP to take an active role in their diabetes management.Practice implicationsUsing a structured conversation model combined with a tool to encourage YP’s agenda-setting and shared decision-making is recommended for more person-centered transitional care in T1DM.     

Mechanisms by which end-of-life communication influences palliative-oriented care in nursing homes: A scoping review

ObjectiveEnd-of-life communication has been largely recognized to promote quality end-of-life care in nursing home (NHs) by increasing residents’ likelihood of receiving comfort-oriented care. This scoping review summarizes what is known about the potential mechanisms by which end-of-life communication may contribute to palliative-oriented care in NHs.MethodsUsing the framework proposed by Arksey and O’Malley and refined by the Joanna Briggs Institute methodology, five literature databases were searched. We extracted 2159 articles, 11 of which met the inclusion criteria: seven quantitative, three qualitative, and one mixed-methods study.ResultsThree mechanisms were identified: a) promotion of family carers’ understanding about their family member’s health condition, prognosis, and treatments available; b) fostering of shared decision-making between health care professionals (HCPs) and residents/family carers; and c) using and improving knowledge about residents’ preferences.ConclusionFamily carers’ understanding, shared decision-making, and knowledge of residents’ preferences contribute to palliative-oriented care in NHs.Practice implicationsDiscussions about end-of-life should take place early in a resident’s disease trajectory to allow time for family carers to understand the condition and participate in subsequent, mindful, shared decision-making. HCPs should conduct systematic and thorough discussions about end-of-life treatment options with all cognitively competent residents to promote informed advance directives.     

Effectiveness of shared decision-making intervention in patients with lumbar degenerative diseases: A randomized controlled trial

ObjectiveTo evaluate the efficacy of shared decision-making (SDM) intervention among patients with lumbar degenerative diseases (LDDs) in terms of decision self-efficacy, control preferences, SDM process, decision satisfaction, and conflict.MethodsA total of 130 outpatients with LDDs recruited from orthopedic or rehabilitation clinics were randomly assigned to the SDM intervention (n = 67) or comparison (n = 63) groups. Patients in the intervention group received decision aids (DAs) with decision coaching and those in controlled group received standard educational materials from a health educator. The primary outcome was decision self-efficacy, and secondary outcomes were control preference, SDM process, conflict, and satisfaction.ResultsThe SDM intervention significantly improved decision self-efficacy (mean difference [MD] = 7.1, 95% confidence interval [CI]: 1.7–12.5, partial η² = 0.05) and reduced conflict (MD = −7.0, 95% CI: −12.2 to −1.9, partial η² = 0.06), especially in patients without family involvement, compared with the health education group. However, no significant between-group differences were observed in other outcomes.ConclusionSDM intervention improved SDM self-efficacy and reduced conflict in patients with LDDs.Practice ImplicationsClinicians can integrate DAs and decision coaching in SDM conversations. SDM intervention seems to engage patients in decision-making, especially those without family involvement.     

Treatment-related communication experiences and expectations among Indian cancer patients receiving radiation therapy and their family members: A qualitative study

ObjectiveTo explore Indian cancer patients’ and their primary family caregivers’ (PFC) experiences and expectations of treatment-related communication with their physician while undergoing radiation therapy.MethodsParticipants, comprising patient-PFC dyads (n = 32), patients only (n = 33) and PFC only (n = 7), were recruited from one hospital in Mumbai, India. Semi-structured interviews explored participants’ perceived role in cancer-related decision-making, diagnosis and prognosis communication experiences with the physician, communication expectations of their treating physician, and information needs. Interviews were audio-recorded, transcribed verbatim, and analysed using the framework approach.ResultsMain themes included: (i) patients’ passive role in treatment communication, (ii) family as an integral part of the medical consultation, and (iii) dyads’ expectations and beliefs about the role of the physician.ConclusionIndian cancer patients played a passive role in treatment decision-making while physicians were seen as primary medical decision-makers. Further, PFCs provided the final consent for the treatment plan and acted as a mediator/moderator between the patient-physician.Practice implicationsThese findings suggest the need for (i) interventions such as question prompt lists that may improve patient activation and caregiver preparedness, and (ii) triadic communication training interventions for optimal communication between the three stakeholders (i.e., patient, physician and PFC).     

Incorporating shared decision making into communication with older adults with cancer and their caregivers: Development and evaluation of a geriatric shared decision-making communication skills training module

ObjectiveThe purpose of this study was to evaluate a Communication Skills Training (CST) module for health care providers (HCPs) applying a shared decision-making approach to a meeting with an older adult with cancer and his/her family.MethodsNinety-nine HCPs from community-based centers, cancer centers, and hospitals in the Northeastern U.S. who worked primarily with older adult patients participated in a CST module entitled Geriatric Shared Decision Making. Participants completed pre- and post-training Standardized Patient Assessments (SPAs) and a survey on their confidence in and intent to utilize skills taught.ResultsResults indicated high HCP satisfaction with the module, with over 95 % of participants reporting high endorsement to all five evaluation items. HCPs’ self-efficacy in utilizing communication skills related to geriatric shared decision making significantly increased pre- to post-training. In standardized patient assessments among a subset of providers (n = 30), HCPs demonstrated improvements in three shared decision-making skills: declare agenda, invite agenda, and check preference.ConclusionA geriatric shared decision-making CST workshop for HCPs showed feasibility, acceptability, and improvement in self-efficacy as well as skill uptake.Practice implicationsThis Geriatric Shared Decision-Making CST module provides an intervention for improving provider-patient-family member communication in the context of cancer care for older adults.     

Simplified Validated Prognostic Model for Progression-Free Survival after Autologous Transplantation for Hodgkin Lymphoma

Hodgkin lymphoma (HL) prognostic models based on factors measured at time of autologous hematopoietic cell transplantation (AHCT) are limited by small sample sizes. Models based on information at diagnosis are often not uniformly collected or available at transplantation. We propose an easily implementable prognostic model for progression-free survival (PFS) post-AHCT based on factors available at transplantation in a large international cohort of HL patients. The outcomes of 728 AHCT recipients for relapsed/refractory HL were studied. Patients were randomly selected for model development (n = 337) and validation (n = 391). The multivariate model identified 4 major adverse risk factors at the time of AHCT with the following relative weights: Karnofsky performance score <90 and chemotherapy resistance at AHCT were each assigned 1 point, whereas at least 3 chemotherapy regimens pre-AHCT and extranodal disease at AHCT were each assigned 2 points. Based on the total score summed for the 4 adverse risk factors, 3 risk groups were identified: low (score = 0), intermediate (score = 1 to 3), or high (score = 4 to 6). The 4-year PFS for the low- (n = 176), intermediate- (n = 261), and high- (n = 283) risk groups were 71% (95% confidence interval [CI], 63% to 78%), 60% (95% CI, 53% to 66%), and 42% (95% CI, 36% to 49%), respectively. The prognostic model was validated in an independent cohort. The Center for International Blood and Marrow Transplant Research model is based on factors easily available at the time of AHCT and discriminates patients with favorable post-AHCT outcomes as well as an intermediate-risk group. This model should assist in the prospective evaluation of alternative treatment strategies.     

What do community-dwelling older adults with chronic pain value in a program of combined pain neuroscience education plus exercise?

ObjectiveTo explore the experience of older adults after a pain neuroscience education (PNE) and exercise intervention.MethodsFocus group interviews were conducted with 14 older adults after receiving 8-weekly sessions of PNE and exercise and encompassed older adults’ perceptions of the intervention and its impact. Interviews were transcribed verbatim and analyzed by 3 researchers using thematic analysis in a five-step approach (compiling, disassembling, reassembling, interpreting, and concluding).ResultsThree themes emerged: pain reconceptualization, motivational factors, and perceived improvements. Pain reconceptualization was illustrated by participants’ ability to use language that related to PNE concepts (n = 12), increased self-efficacy (n = 5), and adjusted emotions (n = 2) and behaviors (n = 6). Motivational factors were the group-administered intervention (n = 6) and the physical therapists’ communication skills (n = 10). The intervention was perceived as having a positive impact on sleep (n = 3), well-being (n = 6), and activity/ability to perform activities (n = 8).ConclusionOlder adults understand PNE concepts and reconceptualize pain. PNE and exercise were perceived as having a positive impact on day-to-day life.Practice ImplicationsMode of administration, communication skills, and rapport are aspects of the intervention that are valued by older adults. Also, PNE might be used as a strategy to increase older adults’ adherence to physical activity.     

“We have no magic bullet”: Diagnostic ideals in veterans’ mild traumatic brain injury evaluations

ObjectiveTo understand military veterans’ and healthcare providers’ experiences identifying veterans’ personal histories of combat-related mild traumatic brain injury (mTBI) months or years after the injury.MethodsPatients and clinical staff of a Veterans Health Administration (VA) Polytrauma/TBI clinic participated in a seven-month ethnographic study, which combined direct observation and interviews with veterans (n = 12) and VA clinicians (n = 11). Data were analyzed thematically.ResultsVeterans and staff have different understandings of the value of neuroimaging in care for patients with post-acute mTBI, and different understandings of the role of diagnostic certainty in clinical care. Veterans sought to understand the relationship between their past head injuries and their current symptoms. Clinicians educated veterans that their symptoms could be caused by multiple factors and embraced ambiguity as part of treating this patient population.ConclusionsPatient-provider communication may be enhanced by conversations about common norms of diagnosis and why evaluating mTBI histories departs from these norms.Practice implicationsClinicians should anticipate that patients may expect a diagnostic process that entails neuroimaging and resolves their uncertainty. In the case of post-acute mTBI, patients would likely benefit from education about the diagnostic process, itself.     

Patients with Dupuytren’s Contracture,Ledderhose Disease,and Peyronie’s Disease are at higher risk of arthrofibrosis following total knee arthroplasty

BackgroundTotal knee arthroplasty (TKA) is a successful treatment for patients with late stage osteoarthritis, yet arthrofibrosis remains a consistent cause of TKA failure. Dupuytren’s, Ledderhose and Peyronie’s Diseases are related conditions of increased fibroblast proliferation. The aim of this study was to identify whether an association exists between these conditions and arthrofibrosis following TKA.MethodsPatient records were queried from 2010 to 2016 using an administrative claims database to compare the rates of arthrofibrosis, manipulation under anesthesia (MUA), lysis of adhesions (LOA), and revision TKA in patients with independent chart diagnoses of Dupuytren’s Contracture, Ledderhose, or Peyronie’s Diseases versus those without. Complications were queried and compared using multivariate logistic regression.ResultsPatients with Dupuytren’s (n = 5,232) and Ledderhose (n = 50,716) had a significantly higher rate of ankylosis following TKA: 30-days (OR, 1.54; OR, 1.23), 90-days (OR, 1.20; OR, 1.24), 6-months (OR, 1.23; OR, 1.23), and 1-year (OR, 1.28; OR, 1.23), while patients with Peyronie’s (n = 1,186) had a higher rate of diagnosis at 6-months (OR, 1.37) and 1-year (OR, 1.35). Patients with diagnoses of any of the fibroproliferative diseases had a statistically higher risk of MUA at 90-days, 6-month, and 1-year following primary TKA. These cohorts did not have a significantly higher rate of revision TKA.ConclusionThere is an increased odds risk of arthrofibrosis and MUA in patients who have undergone TKA and have a diagnosis of Dupuytren’s Contracture, Ledderhose, or Peyronie’s Diseases. Improvements to frequency and application of post-operative treatment should be considered in these cohorts to improve outcomes.     

Communication methods between outpatients with limited-English proficiency and ancillary staff: LASI study results

ObjectiveDescribe communication methods between primary care ancillary staff, including front desk administrative staff and medical assistants (MAs), and patients with limited-English proficiency (LEP).MethodsPatients with LEP completed a telephone survey after a primary care visit including questions about communication with ancillary staff (n = 1029).To inform practice improvements and lend qualitative perspective to these quantitative data, we subsequently conducted semi-structured interviews with ancillary staff and physicians.ResultsProfessional interpreter use was minimal with ancillary staff (<4%). Among patients who did not use their preferred language with bilingual staff, about one-third reported using English to communicate, despite most (≥ 80%) speaking English ‘not well’ or ‘not at all.’ In semi-structured interviews, ancillary staff felt basic English sufficient for most patient communication. However, physicians reported taking on extra visit tasks to compensate for the communication barriers between ancillary staff and patients with LEP.ConclusionsUse of professional interpretation by front desk staff and MAs was minimal. This led many patients with LEP to ‘get by’ with limited English when communicating with ancillary staff, in turn increasing burden on the physician visit.Practice implicationsFuture interventions should focus on increasing use of professional interpretation by outpatient ancillary staff when communicating with LEP patients.     

Shared decision making and other variables as correlates of satisfaction with health care decisions in a United States national survey

Objective

The purpose of this study was to examine the relationship between shared decision-making (SDM) and satisfaction with decision (SWD) within a larger survey of patient decision-making in health care consultations.

Methods

A randomly selected age-proportionate national sample of adults (aged 21–70 years) stratified on race, ethnicity, and gender (N = 488) was recruited from a health research volunteer registry and completed an online survey with reference to a recent health consultation. Measures included the Shared Decision Making-9 questionnaire (SDM-Q-9), Satisfaction With Decision (SWD) scale, sociodemographic, health, and other standardized decision-making measures. Forward selection weighted multiple regression analysis was used to model correlates of SWD.

Results

After controlling for sociodemographic variables, SDM-Q-9 total score was associated with SWD, adjusted R² = .368, p < .001. Three of nine SDM-Q-9 items accounted for significant proportions of variance in SWD.

Conclusion

SDM was positively associated with SWD and was strongest for three areas of SDM: patients being helped in a health care consultation with understanding information, with treatment preference elicitation, and with weighing options thoroughly.

Practice implications

By identifying variables such as SDM that are associated with SWD, health care interventions can better target modifiable factors to enhance satisfaction and other outcomes.     

The verbal Oxford Knee Score is not clinically different from the written score when assessed before or after total knee arthroplasty

BackgroundThe aim of this study was to assess the reliability of the Oxford Knee Score (OKS) collected verbally compared with the validated written score, using a population of patients who underwent total knee arthroplasty (TKR).MethodsNinety patients (mean age 70.6; (43–92), 56.7% female) undergoing TKR were prospectively assessed. One group (n = 45) completed written (standard) and verbal (over the telephone) OKS preoperatively, half (n = 23) performed the written questionnaire first followed by the verbal questionnaire, and the other half (n = 22) performed this in reverse. A separate group (n = 45) completed the same regime one year postoperatively.ResultsA mean difference of 0.63 (95% CI − 0.985–2.23) points between verbal and written OKS was observed preoperatively, and of 1.36 (95% CI − 0.942–3.65) points was observed at one year postoperatively. Excellent reliability was observed using ‘average measures’ intra-class coefficient for the OKS preoperatively (r = 0.848) and at one year postoperatively (r = 0.970) in both groups who had written scores performed first, and those who had verbal scores performed first (preoperative r = 0.780, one year r = 892).Bland and Altman plots demonstrated consistent correlation between patients reporting their preoperative score and one-year postoperative score verbally and written. There was no significant variation between groups who had written scores performed prior to verbal, compared with those who reported verbal scores prior to written.ConclusionsProspective written collection of OKS remains the benchmark. However, verbal recording of OKS is not clinically different to written score, and may be a useful alternative to OKS in patients who are unable to attend or complete written questionnaires.     

Monitoring of autoantibodies against CYP4Z1 in patients with colon,ovarian, or prostate cancer

We have previously monitored the detection of autoantibodies (aAbs) directed against CYP4Z1 in the sera of breast and lung cancer patients. In the present study, the occurence of anti-CYP4Z1 aAbs in patients suffering from colon (n = 100), ovarian (n = 72), or prostate (n = 85) cancer was examined. Determination of aAbs was done using our previously established ELISA method. On average, the levels of anti-CYP4Z1 aAbs detected in sera from all cancer patients were not significantly higher than controls. No correlations were found with respect to gender or tumor stage. However, a subgroup of colon cancer patients with increased anti-CYP4Z1 aAb titers exhibited positive fecal occult blood test (FOBT) results and higher levels of both carbohydrate antigen 19–9 (CA19-9) and carcinoembryonic antigen (CEA). These results do not suggest that anti-CYP4Z1 aAbs have value as an independent biomarker for the detection of either colon, ovarian, or prostate cancer. However, they might be useful in combination with other biomarkers for the identification of a subset of colon cancers. Investigations involving a more powered sample size of this subgroup are needed to support this notion.     

Involving patients in undergraduate health professions education: What’s in it for them?

ObjectivesPatients have become more involved in research, policy, and health professions education. They are involved in teaching students competencies required for person-centred care, but patient benefits have not received proper attention. This exploratory study identifies how patient involvement in health professions education help patients to practice self-management and shared decision-making.MethodsIndividual interviews were conducted with patients (hereafter ‘experts by experience’) (N = 11) who participated in the Patient As a Person Module, organised for students of health professions in The Netherlands. Additionally, one of their healthcare professionals (N = 10) and family members (N = 9) were interviewed. Directed content analysis was used.ResultsParticipants reported that sharing lived experiences helped experts by experience to reflect on their preferences regarding health and healthcare, accept their changed selves, and obtain a renewed sense of purpose. They reported gaining insight into the perspectives of healthcare professionals, which yielded more equal healthcare professional-patient relationships.ConclusionsSharing their lived experiences with health and health care with students could help patients in practising effective self-management and participate in shared decision-making.Practice implicationsApproaching patient involvement in health professions education from both the perspectives of students and experts by experience, as opposed to students alone, optimises its societal impact.     

Autologous Transplantation for Transformed Non-Hodgkin Lymphoma Using an Yttrium-90 Ibritumomab Tiuxetan Conditioning Regimen

Transformation from indolent non-Hodgkin lymphoma (NHL) to diffuse large B cell lymphoma (DLBCL) has historically been associated with a poor prognosis. A small series of autologous stem cell transplantation (ASCT) studies using conventional conditioning regimens has demonstrated durable progression-free survival (PFS) rates ranging from 25% to 47%, but data in the rituximab era are lacking. Here we report the results of a multicenter retrospective trial evaluating ASCT in patients with transformed lymphoma using the Z-BEAM conditioning regimen, which combines yttrium-90–labeled ibritumomab tiuxetan (Zevalin) with high-dose BEAM (carmustine, etoposide, cytarabine, melphalan) chemotherapy. Sixty-three patients from 4 institutions were treated between 2003 and 2011. Histological confirmation of transformation was required and defined as a diagnosis of DLBCL in patients with either a prior history or concomitant diagnosis of low-grade B cell NHL. Median patient age at ASCT was 59.5 years, median number of prior regimens was 2, and all patients were exposed to rituximab. Disease status at ASCT was as follows: first complete remission (CR) (n = 30), first partial remission (n = 11), first relapse (n = 14), and at least second CR (n = 8). The median time from diagnosis of histological transformation to ASCT was 7.5 months (range, 2.8 to 116). Two-year nonrelapse mortality was 0%. Median follow-up for living patients was 28 months (range, 5 to 103). Two-year PFS was 68% (95% confidence interval, 58% to 75%), and overall survival was 90% (95% confidence interval, 80% to 95%). In conclusion, the Z-BEAM conditioning regimen for ASCT is well tolerated by patients with transformed lymphoma and demonstrates encouraging clinical outcomes.     

Bortezomib for Refractory Autoimmunity in Pediatrics

Therapy of refractory autoimmunity remains challenging. In this study, we evaluated the therapeutic effect of bortezomib, a proteasome inhibitor, by targeting plasma cells in 7 patients (median age, 9.9 years). Four doses of bortezomib were administered at a dose of 1.3 mg/m² intravenously (n = 6) or subcutaneously (n = 1) every 72 hours. Bortezomib was administered at a median of 120 days from laboratory confirmation of autoantibodies. All patients had failed 2 or more standard therapies. Rituximab was administered on the first day if B cells were present, and all patients received plasmapheresis 2 hours before bortezomib administration. Six patients experienced resolution of cytopenias. Two of 6 patients experienced recurrence of cytopenias after initial response. Adverse effects include nausea (n = 1), thrombocytopenia (n = 2), Clostridium difficile colitis (n = 1)), febrile neutropenia (n = 1), and cellulitis at the subcutaneous injection site (n = 1). Our experience suggests that bortezomib may be beneficial in the treatment of refractory autoimmunity in children.     

Assessment of medical students’ shared decision-making skills in simulated physician-patient encounters

ObjectiveTo compare shared decision-making skills of medical students who voluntarily translate medical documents into plain language with students who do not participate in this voluntary task.Methods29 medical students who voluntarily translated medical documents for patients into plain language on the online-platform https://washabich.de (WHI group) and 29 medical students who did not (non-WHI group) participated in a simulated virtual consultation hour. Via skype, participants communicated with six simulated patients. All conversations were transcribed and a blinded rater assessed them with the OPTION scale for shared decision-making.ResultsThe WHI group received significantly (p < .001) higher total scores for shared decision-making with the OPTION scale than the non-WHI group. The greatest differences in scores were found for the items “The clinician checks that the patient has understood the information.” (WHI: 2.98 ± 0.77 vs. non-WHI: 2.61 ± 0.89, p < .001) and “The clinician offers the patient explicit opportunities to ask questions during the decision-making process.” (WHI: 2.83 ± 1.00 vs. non-WHI: 2.40 ± 1.07, p < .001).ConclusionWritten translation of medical documents is associated with significantly better OPTION scores for shared decision-making in simulated physician-patient encounters.Practice ImplicationsTo use written medial translation exercises in general to improve medical students’ shared decision-making skills.