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

Journal Pre-proof Educational Programs to Teach Shared Decision Making to Medical Trainees: A Systematic Review Naykky Singh Ospina, Freddy J.K. Toloza, Francisco Barrera, Carma L. Bylund, Patricia J. Erwin, Victor Montori

PII:

S0738-3991(19)30560-9

DOI:

https://doi.org/10.1016/j.pec.2019.12.016

Reference:

PEC 6486

To appear in:

Patient Education and Counseling

Received Date:

11 April 2019

Revised Date:

6 November 2019

Accepted Date:

23 December 2019

Please cite this article as: Singh Ospina N, Toloza FJK, Barrera F, Bylund CL, Erwin PJ, Montori V, Educational Programs to Teach Shared Decision Making to Medical Trainees: A Systematic Review, Patient Education and Counseling (2020), doi: https://doi.org/10.1016/j.pec.2019.12.016

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.

Educational Programs to Teach Shared Decision Making to Medical Trainees: A Systematic Review. Naykky Singh Ospina, MD,MS1; Freddy JK Toloza, MD2,3; Francisco Barrera, MD3; Carma L. Bylund, PhD4; Patricia J. Erwin, MLS5,Victor Montori, MD,MS3,6.

Division of Endocrinology, University of Florida, Gainesville, US Division of Endocrinology, University of Arkansas for Medical Sciences, Little Rock, US Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, US College of Journalism and Communications, University of Florida, Gainesville, US Mayo Clinic Libraries, Mayo Clinic, Rochester, US Division of Endocrinology, Mayo Clinic , Rochester, US

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Tables and Figures: 2 figures, 5 tables, 3 supplemental tables and appendix.

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(1) (2) (3) (4) (5) (6)

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Word Count: 3863

Funding source: none

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Conflict of Interest: none

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Key Words: shared decision making, medical trainees, patient-centered care

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Author contribution: NSO, FT, FB, PE conceptualized the study. NSO, FT, FB acquired and analyzed the data. VM provided input on the concept/design of the study, analysis and interpretation of the data. CB provided input on the analysis and interpretation of the data. All authors revised the manuscript and provided approval of the final version.

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Corresponding Author

Naykky Singh Ospina, MS, MD 1600 SW Archer Road Room H2 PO Box 100226 Gainesville, FL 32610 [email protected]

Highlights   

Educational programs to teach SDM to medical trainees most commonly combine teaching strategies Very Low quality evidence suggest interventions to teach SDM to medical trainees are viewed as satisfactory Future educational programs should include a clear plan for outcome assessment focused on their impact on clinical practice

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Abstract

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Objective

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Shared 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. Methods

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We 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. Results

Conclusion

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Eighteen 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.

Very 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.

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Practical Implications

Integration of formal and systematic outcomes evaluation (effects on behavior/clinical practice) should be part of future programs.

1. Introduction Adequate communication between patients and clinicians is a core principle of medicine. This communication process should allow patients and clinicians to collaborate when making medical

decisions and identify the next best step for each patient.1-3 Clinicians care for patients with multiple and complex medical conditions for which multiple treatment options (with different safety and efficacy profiles) are available. Understanding the patient’s situation and how they value different medical alternatives is imperative in order to provide care. This collaboration between patients and clinicians, also known as shared decision-making (SDM), can help clinicians provide patient-centered care.1,2,4 In fact, the use of tools to support SDM in clinical practice helps patients make medical decisions that are

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consistent with their informed values and be more knowledgeable and active during the decision

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making process.5 Although, implementing effective SDM in clinical practice is a goal, its full

implementation is limited by factors related to the health care system, clinicians and patients. Common

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barriers to implementation from a clinician perspective include lack of knowledge and familiarity with

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SDM and time constraints.6,7

Educational programs have successfully been developed to improve patient and clinician

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communication.8 Barriers to the implementation of these educational programs include: 1) time constraints for their development and facilitation, 2) adequate participation by trainees due to other

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clinical and educational demands, 3) limited financial resources, and 4) a working environment where good communications skills are not supported or valued.9-11 A recent review evaluating the effect of SDM training in the undergraduate medical curriculum found an overall positive impact of these programs. However, this review did not include studies involving residents/fellows and did not evaluate

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the quality of the included studies or the overall body of evidence.12 In recent years, there has been increased emphasis on improving the communication skills of graduate medical trainees as highlighted by the recognition of interpersonal and communication skills as one of the core competencies for clinicians in training recognized by the Accreditation Council for Graduate Medical Education.13 As a result, 148 training programs for SDM have been developed around the world between 2011-2015, which represents an increase of 174% in the last four years.14 However, the effectiveness of these now

common educational programs to teach SDM, in particular those directed at graduate medical trainees, has not been systematically assessed and synthesized as a body of research. To address this knowledge gap and inform the development of future education programs we conducted a systematic review to evaluate the current literature addressing the outcomes of educational programs that aim to teach SDM to clinicians in training.

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2. Methods This systematic review was conducted following a protocol and is reported according to current

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standards (Preferred reporting items for systematic reviews and meta-analysis, PRISMA).15

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2.1 Eligibility Criteria

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Studies were eligible for this review if they assessed the outcomes of an educational program aimed at improving SDM skills of medical trainees (students, residents, and fellows). We considered an

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educational program any structured activity that had the aim of teaching SDM, such as workshops, courses, or classes. In general, medical students referred to those enrolled in a program seeking the

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professional degree of physician. A resident is a physician that has graduated medical school and is receiving further training to specialize in a particular area of medicine. A fellow is a physician who has completed residency and is seeking further specialty training. We included studies in which the authors explicitly described teaching SDM in their manuscript or an intervention that aimed to engage patients

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in medical decision-making and taught different models of decision making (including SDM) to participants. Studies that included educational programs aimed at improving overall communication skills but that did not clearly define a SDM component or a specific outcome related to the SDM intervention (in addition to course satisfaction) were excluded. We also excluded studies that assessed SDM skills but in which students did not participate in a formal educational activity. No restrictions by language, publication year/status, or type of study were used.

2.2 Search Strategy A comprehensive search of multiple databases including Ovid Medline, Embase, Cochrane Central Registry of Controlled Trials, Cochrane Database of Systematic Reviews, Cochrane Methodology Register, Database of Abstracts of Review of Effects and Health Technology Assessment was performed from inception to October 2018 (Appendix 1). An experienced medical librarian (PE) developed the

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search strategy in collaboration with the first author (NSO.) We (NSO, FJT) reviewed the reference list of the included studies to identify articles that could have been missed by the initial search.

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2.3 Study Selection

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Reviewers (NSO, FJT, FB) worked independently and in duplicate to evaluate the identified abstracts according to the inclusion criteria. The full text of articles that met the inclusion criteria based on their

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abstract review were reviewed to determine eligibility. We used standardized, piloted eligibility

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screening tools for both abstract and full text screening that were based on the inclusion criteria (population, intervention and outcomes of interest). In the abstract screening section, all articles in which one of the reviewers considered further evaluation was needed to determine eligibility were

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automatically evaluated in the next step (full text review level). Disagreement at the abstract screening level was not quantified as it did not affect inclusion and/or further review of the article. We resolved disagreements about study eligibility in the full text review level by consensus. Cohen’s

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Kappa was 0.70 at the full text screening level. 2.4 Data Collection and Data Items We extracted relevant data (NSO, FJT, FB) from the final included articles independently and in duplicate using a standardized electronic form, following a pilot test of four articles to achieve calibration. We extracted data about the study setting, participants, educational intervention, and outcomes.

Clarification regarding study eligibility and/or data for inclusion in the review was required in 20 studies and we contacted the study authors. The authors of 11 of these studies replied with clarifications. 2.5 Risk of Bias We used a modified Newcastle Ottawa Scale and the Cochrane Risk of Bias Tool for randomized control trials (RCT) to assess the risk of bias.16,17 Reviewers assessed the risk of bias working independently and

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in duplicate, using a standardized extraction form. (NSO, FJT, FB)

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2.6 Data Synthesis, Summary Measures and Sensitivity Analysis

Descriptive statistics were used to summarize the variables of interest. We assessed the clinical

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heterogeneity of the studies based on the included populations, interventions and outcomes. Due to

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significant difference in the educational programs and measured outcomes, we decided against performing a meta-analysis; instead, a narrative synthesis of the studies is presented.

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We classified the effects of the educational intervention on outcomes following Kirkpatrick’s framework for educational programs that is based on their impact on learners’ reaction, learning, behavior and

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results. This framework can help educators have a better understanding of the impact and value of their educational programs and has been extensively used in the literature.18,19 3. Results

3.1 Study Selection and Characteristics

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We identified 4069 studies in our systematic literature search and included 18 in the analysis (Figure 1).20-37 Studies were published between 1992 and 2018 and most were conducted in North America. Two RCTs were identified.30,33 Most studies reported a funding source (12/18, 67%). (Table 1) 3.2 Setting and Population

Most educational programs were conducted in university-based centers. The studies had samples sizes ranging from 11 to 267 participants and focused on residents (10/18, 56%), medical students (7/18, 39%) and fellows (1/18, 5%) (Table 2). 3.3 Educational Programs and Evaluation Most studies (13/18, 72%) taught SDM in the setting of a particular clinical process (e.g., prescription

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discussion, surgical or ICU setting). There were different definitions of SDM used in these courses, however, overall agreement on the principles of collaboration and importance of patient’s values and

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preferences were noted (Supplemental Table 1).

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Most interventions that were directed at residents and/or fellows were described as workshops, seminars, or lectures that were received as part of each program educational curriculum. In the case of

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programs aimed at medical students, these were commonly described as electives or courses while

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others were embedded in the educational structure of clerkships. Educational programs included multiple modalities of education independent of the targeted population (Table 2).

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Educational programs aimed at teaching SDM skills mostly included in person didactics (15/18, 83%), feedback and debriefing (12/18, 67%), group discussions (11/18, 61%), practice with a standardized patient (9/18, 50%) and online didactics (7/18, 39%). Less commonly, participants were provided with resources for use in practice or reading material, or had the educational program delivered in the clinic.

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Most educational programs lasted between 2-8 hours, although a few were embedded into longer programs (Table 2).

Most studies focused on the evaluation of participants’ attitudes, confidence, or comfort with SDM (12/18, 67%) and satisfaction with the course (6/18, 33%). Knowledge and communication skills were evaluated by four and five studies (only four studies reported outcomes), respectively. Only three

studies focused on the effect of the educational program on behavior (two reported outcomes) and two studies focused on clinical outcomes (Figure2). 3.4 Risk of Bias The included studies were in general at moderate to high risk of bias. RCTs reported unclear methods of randomization and blinding. Observational studies did not evaluate outcomes of interest at baseline, match participants for prognostic factors, or consider co-interventions (e.g. other educational activities).

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Outcome evaluation was performed at short follow up periods (Supplemental Tables 2 and 3).

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3.5 Evaluation of the Educational Intervention

1) Satisfaction with the Educational Program and Knowledge about SDM

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Overall, educational programs teaching SDM were rated as satisfactory by participants.21-23,26,28,29 Improvement in knowledge was evaluated in four studies (one qualitative).20,25,32,37 Qualitative

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assessment showed students used language that indicated understanding of SDM concepts.32 Two

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studies showed statistically significant improvement in knowledge. (Table 3) 2) Attitudes, Comfort, Confidence and Self-Perceived skills

23,26-29,31-33,35

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Twelve studies evaluated attitudes, comfort, confidence and self-perceived skills of the participants.20Six studies evaluated participants before and after training: four of these studies showed

statistical improvement in these outcomes, while two found no difference. Three studies included qualitative assessments that were positive in regards to the importance of SDM in clinical practice and

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the ability of the participant to engage in SDM. A randomized study evaluating the effect of an interactive web based program for the management of opioid therapy for chronic pain randomized ~200 internal medicine residents and found no difference in a questionnaire assessing physician patient centeredness.(Table 4)33 3) Skills, behavior and clinical outcomes

Four studies were able to report the impact of the educational strategy on the participants’ SDM skills. None showed statistically significant differences. The tools that were used to assess the participants’ SDM skills included the Option score, Decision support analysis tool, and tools developed for each individual study.20,21,29,36 Three studies attempted to measure effect of the educational programs on clinical behavior.21,23,24 One

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of the studies only obtained one recording in clinical practice, so no conclusions were made.23 Another study found that 94% of the participants reported using SDM in clinical practice during the 6 months

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documentation about SDM in 49% of the study participants.34

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following the educational intervention.21 The other study that evaluated behavior, found clinical

Two studies focused on clinical outcomes, including change in antibiotic prescription patterns

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(educational intervention group showed benefit of decreased antibiotic prescription for viral respiratory

4. Discussion and Conclusion

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4.1 Discussion

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infections). A study including anesthesia residents found no effect on patient satisfaction.24,30 (Table 5).

Educational programs to teach SDM to medical trainees most commonly combine a didactic component with a practical experience and time for feedback and group discussion. Less commonly, tools for implementing SDM in clinical practice are provided to participants. Formal assessment and reporting of

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these programs are heterogeneous in nature and focused mostly on the effects of the intervention on participant satisfaction and attitudes, comfort, and confidence with SDM. Very low quality evidence suggest that SDM educational programs have a positive effect on these attributes and SDM knowledge. Their impact on clinical skills, behaviors and patient outcomes is less clear, as data on these outcomes is based on few observations and results are conflicting.

In order to evaluate teaching strategies aimed specifically at SDM, we only included studies in which authors clearly defined and measured outcomes related to SDM. Although, this approach allowed us to include studies with similar goals it could have resulted in exclusion of programs in which SDM was taught although not explicitly or in association with other communication strategies. An important limitation of our study is that it is based only on educational interventions whose effects have been evaluated and published. We also did not perform a content analysis of the curriculum or materials of

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each educational program. However, there seems to be an alignment in some of the elements used to

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define SDM (Supplemental Table 1). Obtaining further information on the content of these

educational programs would be important given the lack of consensus on how to define SDM. In fact,

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multiple definitions of SDM are available and vary between conceptual to more practical step-by-step approaches, or frameworks where specific components are requirements of SDM.38-42 A commonly

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cited model defines SDM as an exchange in which information giving and deliberation between

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patients and healthcare professionals is interactional, the parties work together towards reaching agreement on treatment plans and all parties have an investment on the decision made.43 One broad and conceptual definition suggests that in SDM patients and clinicians work together to understand

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the patient’s situation and determine how to best address it.44 Similarly, SDM has been defined as an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported when considering options, to achieve informed

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preferences.40,45 Although an absolute consensus on a definition of SDM is not available, authors have suggested that teaching SDM requires at least two groups of communication competencies: 1) relational competencies (create a favorable environment for communication) and 2) risk communication competencies (allow discussion of uncertainty as it relates to risks and benefits).41 This lack of consensus on how to define SDM in theoretical and practical steps increases the complexity

of evaluating and successfully teaching this concept to medical trainees, even if there is more overlap than discrepancies between definitions. Due to the heterogeneity of reported outcomes, we are unable to provide summary statistics related to expected effect estimates or explore variables associated with outcomes. A systematic review including 41 articles evaluated the outcomes of training in SDM for health care providers, and found significant

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variation in the outcomes that were assessed, underscoring the need for agreement on a core set of validated outcomes that can inform the development of future programs. A proposed framework

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focuses on the health care provider reaction, learning, behavior and SDM results, similar to the

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framework used in our review of the literature .46

There is also lack of consensus regarding the outcomes that should be measured when evaluating

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interventions to support SDM in practice. A new framework suggested that the process of collaborative deliberation can lead to proximal, distal and distant effects all of which should be evaluated in trials of

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SDM supporting interventions.47 Both of these limitations of the literature (definition and outcome assessment) highlight the complex field of communication and educational research on the principles

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of SDM. 46,47

Strengths of this analysis include that most steps of this review were conducted in duplicate, authors were contacted for clarifications and our search was designed with the assistance of a medical

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librarian.48-50

Our findings suggest that participants commonly rate these educational programs as satisfactory. This finding might be related to an interest for training in SDM in medical trainees. For example, a study of more than 300 senior medical students in Peru found that only 2% had received theoretical or practical training in SDM, but up to 53% considered this communication approach as ideal, comparable to students in Germany where up to 62% considered SDM as ideal.51,52 Similarly, a study of 70 first year

residents in the US found that 60% had not received any education on SDM, >90% considered SDM important in clinical practice and 57% considered lack of education a barrier to the implementation of SDM.53 In contrast, a study of Swiss residents found negative attitudes towards SDM.54 An umbrella review of 12 systematic reviews evaluating communication skills training for clinicians found that single-day programs that are learner centered, focused on practice and utilize multiple

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teaching strategies (role play, feedback, small group) appeared to be the most effective.8 Most of the educational programs included in our review followed this framework and focused on achieving

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satisfaction with the training and to produce changes in participants’ attitudes and comfort with SDM.

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A limited number of studies evaluated SDM skills and overall no significant improvement was noted. In contrast, Hoffmann et al conducted a RCT including students of multiple disciplines and found significant

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improvement in SDM skills two weeks after the training module.55 Our findings are consistent with previous reports that highlighted the need to move beyond these initial goals and assess the effect of

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communication courses on producing changes in behavior and activities in clinical practice.56 For example, the results of a systematic review evaluating 19 RCTs of communication skills training for

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physicians found low quality evidence suggesting only a small impact on patient outcomes.57 A systematic review of seven studies evaluating the effect of communication skills training on cancer care outcomes found low quality evidence suggesting no significant effect.58 A study including 45 health professionals that participated in a nine-month communication educational experience assessed the use

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of the acquired communication skills in real life situations and found improvement on skills during real life encounters in a three-months follow-up. These findings, highlight the feasibility and importance of moving beyond study designs that do not allow high quality evaluation of the impact of these educational programs on clinical outcomes.59 However, finding a difference on these important outcomes might be challenging when the participants are physicians in training given that their interaction with patients is different when compared with faculty (e.g. established panel, schedule).

4.2 Implications for Practice/Research Although a large number of training programs are developed annually to improve SDM skills in medical trainees, only a small number of these programs evaluate their effectiveness, and methodological limitations limit our confidence in their results.12,14 In our study we further identified challenges for assessing, comparing and potentially improving these educational programs including: 1) lack of an universal definition of SDM (limiting our ability to standardize the educational intervention), and 2)

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lack of standardized outcome assessment protocol and tools.

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Authors have proposed that communication skills training can be conceptualized as a series of verbal procedures that require formal teaching and evaluation, similar to other procedures and skills taught in

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medicine.11,60 Moreover, in order for clinicians to practice SDM, a core set of communication skills and ethical alignment with the principles of SDM will be required making the successful development and

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implementation of educational programs to teach SDM complex and challenging.11,40,61 For example,

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deliberate practice in which individuals focus their efforts to achieve a state of increased performance (in this case communication skills, SDM) would be required for the long-term success of these

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educational programs. This theory (deliberate practice) suggest that short interventions are unlikely to have sustained effects, as deliberate practice and feedback are needed to achieve the desired skills. A goal directed training with immediate feedback, where the individual seeks to go beyond their current performance is more likely to be successful. However, this approach requires long-term commitment

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and deliberate practice with the help of a supervisor that is effective and reliable in the practice of SDM. 62 63

Another proposed strategy to facilitate the development and evaluation of communication programs is to focus on the concept of manualized communication interventions, based on a detailed guide that directs the clinician through a medical situation. This type of educational program has the advantage of providing a granular description of the intervention that can more easily be replicated. Although in the

field of patient and clinician communication, concerns regarding the lack of flexibility of manuals and replacement of clinical judgement arise. However, using these approaches in educational programs for SDM will require a consensus on a clear definition of SDM, support for long term interventions and clarification of the outcomes of importance for learners, teachers, patients and the healthcare system.64 A systematic review that evaluated 14 instruments developed for educational programs assessing

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patient centered communication found methodological limitations and lack of validation on these instruments.65 A study evaluating rating scales used for assessment of communication skills during the

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objective structure clinical examination had similar findings.66 Consensus on the most appropriate tools to measure these important outcomes would facilitate the evaluation of SDM training programs in the

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future.

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As these educational programs are time consuming for those leading and attending them, future studies should focus on evaluating their impact in clinical practice. Specifically, future studies should measure if

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training future physicians leads to better integration of SDM in clinical practice, as these educational programs aim to improve knowledge and familiarity with SDM, a common perceived barrier.6,41,67,68

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Another important barrier to explore is resistance or lack of role models in clinical practice, as this new generation of clinicians trained with a new focus on patient-clinician communication and SDM, continues training and starts providing care as junior faculty. For example, Peruvian medical students perceived only 10% of faculty as endorsing SDM.51 A study from teachers in Sweden found some of them

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had negative attitudes towards SDM and did not believe they need further education in communication.54

Achieving SDM skills, is likely an example of high level of expertise in clinical communication. Multiple barriers to achieving this level of expertise by clinicians include inaccurate self-assessment of communication skills, lack of understanding about the potential benefits of educational programs and

lack of available programs and role models. In a broader aspect, the lack of incentives and value of communication skills in the healthcare system environment makes achieving excellent SDM skills a challenge.60 As the teaching of SDM to medical trainees moves forward, authors have suggested that future programs should be interactive, include multiple teaching strategies, provide resources and reminders

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for application in practice and focus on allowing clinicians/patients to work together. Moreover, integration of SDM in the medical curriculum and clinical practice setting instead of the current models

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where these educational activities are viewed as additions and/or separate from the usual medical

curriculum have been recommended.6,41,67,68 Our findings, suggest that at this time only a minority of

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these programs provide resources for integration of SDM in clinical practice. In addition, only one of the

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studies included fellows in training a group who would benefit from SDM training as they acquire

4.3 Conclusion

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specialty training.

Very low quality evidence suggest that educational programs to teach SDM to medical trainees are

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viewed as satisfactory by participants and improved their attitudes, perceptions and confidence related to SDM, however, limited evidence regarding their effect on communication skills or clinical outcomes is available. The development of future educational strategies should include a clear plan for outcome

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assessment that goes beyond these initial outcomes and focuses on their impact on clinical practice as well as explores the barriers that limit the implementation of newly acquired SDM skills.

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Chesney T, Devon K. Training surgical residents to use a framework to promote shared decisionmaking for patients with poor prognosis experiencing surgical emergencies. Can J Surg. 2018;61(2):114-120. Hauser K, Koerfer A, Niehaus M, Albus C, Herzig S, Matthes J. The prescription talk - an approach to teach patient-physician conversation about drug prescription to medical students. GMS J Med Educ. 2017;34(2):Doc18. Simmons L, Leavitt L, Ray A, Fosburgh B, Sepucha K. Shared Decision Making in Common Chronic Conditions: Impact of a Resident Training Workshop. Teach Learn Med. 2016;28(2):202-209. Mitchell JD, Ku C, Wong V, et al. The Impact of a Resident Communication Skills Curriculum on Patients' Experiences of Care. A A Case Rep. 2016;6(3):65-75. Dion M, Diouf NT, Robitaille H, et al. Teaching Shared Decision Making to Family Medicine Residents: A Descriptive Study of a Web-Based Tutorial. JMIR Med Educ. 2016;2(2):e17. Cohen RA, Jackson VA, Norwich D, et al. A Nephrology Fellows' Communication Skills Course: An Educational Quality Improvement Report. Am J Kidney Dis. 2016;68(2):203-211. Bhatt NR, Doherty EM, Mansour E, Traynor O, Ridgway PF. Impact of a clinical decision making module on the attitudes and perceptions of surgical trainees. ANZ J Surg. 2016;86(9):660-664. Yuen JK, Mehta SS, Roberts JE, Cooke JT, Reid MC. A brief educational intervention to teach residents shared decision making in the intensive care unit. J Palliat Med. 2013;16(5):531-536. Stacey D, Samant R, Pratt M, Legare F. Feasibility of training oncology residents in shared decision making: a pilot study. J Cancer Educ. 2012;27(3):456-462. Legare F, Labrecque M, Cauchon M, Castel J, Turcotte S, Grimshaw J. Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial. CMAJ. 2012;184(13):E726-734. von Lengerke T, Kursch A, Lange K, MHH AP-L. The communication skills course for second year medical students at Hannover Medical School: An evaluation study based on students' selfassessments. GMS Z Med Ausbild. 2011;28(4):Doc54. Morrow CE, Reed VA, Eliassen MS, Imset I. Shared decision making: skill acquisition for year III medical students. Fam Med. 2011;43(10):721-725. Sullivan MD, Gaster B, Russo J, et al. Randomized trial of web-based training about opioid therapy for chronic pain. Clin J Pain. 2010;26(6):512-517. Peters AS, Schnaidt KN, Seward SJ, Rubin RM, Feins A, Fletcher RH. Teaching care management in a longitudinal primary care clerkship. Teach Learn Med. 2005;17(4):322-327. Kalet AL, Janicik R, Schwartz M, Roses D, Hopkins MA, Riles T. Teaching Communication Skills on the Surgery Clerkship. Med Educ Online. 2005;10(1):4382. Solomon DJ, Laird-Fick HS, Keefe CW, Thompson ME, Noel MM. Using a formative simulated patient exercise for curriculum evaluation. BMC Med Educ. 2004;4:8. Johnson SM, Kurtz ME, Tomlinson T, Fleck L. Teaching the process of obtaining informed consent to medical students. Acad Med. 1992;67(9):598-600. Stiggelbout AM, Pieterse AH, De Haes JC. Shared decision making: Concepts, evidence, and practice. Patient Educ Couns. 2015;98(10):1172-1179. Lin GA, Fagerlin A. Shared decision making: state of the science. Circ Cardiovasc Qual Outcomes. 2014;7(2):328-334. Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361-1367. Legare F, Moumjid-Ferdjaoui N, Drolet R, et al. Core competencies for shared decision making training programs: insights from an international, interdisciplinary working group. J Contin Educ Health Prof. 2013;33(4):267-273.

ur na

21.

38. 39. 40. 41.

48. 49.

50. 51. 52. 53. 54. 55.

56. 57.

Jo

58.

of

47.

ro

46.

-p

45.

re

44.

lP

43.

Wohlgemuth C, Penman K, Desai M, Nolan K, Taske N, Chrisp P. Reaching a shared understanding of shared decision making in health care: NICE's experience of scoping the shared decision making guideline. J Eval Clin Pract. 2019. Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med. 1997;44(5):681-692. Montori VM, Kunneman M, Brito JP. Shared Decision Making and Improving Health Care: The Answer Is Not In. JAMA. 2017;318(7):617-618. Elwyn G, Laitner S, Coulter A, Walker E, Watson P, Thomson R. Implementing shared decision making in the NHS. BMJ. 2010;341:c5146. Muller E, Strukava A, Scholl I, et al. Strategies to evaluate healthcare provider trainings in shared decision-making (SDM): a systematic review of evaluation studies. BMJ Open. 2019;9(6):e026488. Elwyn G, Frosch DL, Kobrin S. Implementing shared decision-making: consider all the consequences. Implement Sci. 2016;11:114. Mullan RJ, Flynn DN, Carlberg B, et al. Systematic reviewers commonly contact study authors but do so with limited rigor. J Clin Epidemiol. 2009;62(2):138-142. Spencer-Bonilla G, Singh Ospina N, Rodriguez-Gutierrez R, et al. Systematic reviews of diagnostic tests in endocrinology: an audit of methods, reporting, and performance. Endocrine. 2017;57(1):18-34. Spencer AJ, Eldredge JD. Roles for librarians in systematic reviews: a scoping review. J Med Libr Assoc. 2018;106(1):46-56. Zeballos-Palacios C, Quispe R, Mongilardi N, et al. Shared decision making in senior medical students: results from a national survey. Med Decis Making. 2015;35(4):533-538. Schneider HB, Sandholzer H. Shared decision making: evaluation of German medical students' preferences. J Eval Clin Pract. 2008;14(3):435-438. Caldwell JG. Evaluating attitudes of first-year residents to shared decision making. Med Educ Online. 2008;13:10. van der Horst K, Giger M, Siegrist M. Attitudes toward shared decision-making and risk communication practices in residents and their teachers. Med Teach. 2011;33(7):e358-363. Hoffmann TC, Bennett S, Tomsett C, Del Mar C. Brief training of student clinicians in shared decision making: a single-blind randomized controlled trial. J Gen Intern Med. 2014;29(6):844849. Deveugele M. Communication training: Skills and beyond. Patient Educ Couns. 2015;98(10):1287-1291. Oliveira VC, Ferreira ML, Pinto RZ, Filho RF, Refshauge K, Ferreira PH. Effectiveness of Training Clinicians' Communication Skills on Patients' Clinical Outcomes: A Systematic Review. J Manipulative Physiol Ther. 2015;38(8):601-616. Uitterhoeve RJ, Bensing JM, Grol RP, Demulder PH, T VANA. The effect of communication skills training on patient outcomes in cancer care: a systematic review of the literature. Eur J Cancer Care (Engl). 2010;19(4):442-457. Carvalho IP, Pais VG, Silva FR, et al. Teaching communication skills in clinical settings: comparing two applications of a comprehensive program with standardized and real patients. BMC Med Educ. 2014;14:92. Back AL, Fromme EK, Meier DE. Training Clinicians with Communication Skills Needed to Match Medical Treatments to Patient Values. J Am Geriatr Soc. 2019;67(S2):S435-S441. Pollard S, Bansback N, Bryan S. Physician attitudes toward shared decision making: A systematic review. Patient Educ Couns. 2015;98(9):1046-1057.

ur na

42.

59.

60. 61.

64.

65.

66.

67.

Jo

ur na

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68.

of

63.

Ericsson KA. Acquisition and maintenance of medical expertise: a perspective from the expertperformance approach with deliberate practice. Acad Med. 2015;90(11):1471-1486. Bhatti NI, Ahmed A. Improving skills development in residency using a deliberate-practice and learner-centered model. Laryngoscope. 2015;125 Suppl 8:S1-14. Weiner JS, Arnold RM, Curtis JR, Back AL, Rounsaville B, Tulsky JA. Manualized communication interventions to enhance palliative care research and training: rigorous, testable approaches. J Palliat Med. 2006;9(2):371-381. Brouwers M, Rasenberg E, van Weel C, Laan R, van Weel-Baumgarten E. Assessing patientcentred communication in teaching: a systematic review of instruments. Med Educ. 2017;51(11):1103-1117. Comert M, Zill JM, Christalle E, Dirmaier J, Harter M, Scholl I. Assessing Communication Skills of Medical Students in Objective Structured Clinical Examinations (OSCE)--A Systematic Review of Rating Scales. PLoS One. 2016;11(3):e0152717. Legare F, Adekpedjou R, Stacey D, et al. Interventions for increasing the use of shared decision making by healthcare professionals. Cochrane Database Syst Rev. 2018;7:CD006732. Perron NJ, Sommer J, Hudelson P, et al. Clinical supervisors' perceived needs for teaching communication skills in clinical practice. Med Teach. 2009;31(7):e316-322.

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Records identified through database searching (n = 4069)

Records screened (n = 4069)

Screening

Records excluded (n =3927)

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Full-text articles assessed for eligibility (n =142)

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Eligibility

Included

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Identification

Figure 1. Study selection

Studies included in qualitative synthesis (n =18)

Full-text articles excluded, (n =125) Did not meet inclusion criteria (population, intervention, outcomes of interest)

Added from manual review (n =1)

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Figure 2. Evaluation of education interventions to teach SDM to medical trainees

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VERY LOW QUALITY OF THE EVIDENCE: 1) Moderate to high risk of bias, 2) High risk of publication bias, 3) Small effect size

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Outcomes : (1) Satisfaction, (2) Knowledge, (3) Attitudes/Comfort, (4) Practical Skills, (5) Behavior, (6) Patient Outcomes Table 1. Summary of Included Studies

Country

Participation Type of Study Rate (%)

SDM specific

Canada

50

Observational (before and after)

Rusiecki, 2017 Hauser, 2017 Dion, 2016

US

94

Germany

NR

Canada

28

Morrow, 2011 Cohen, 2016 Bhatt, 2016

US

NR

US

100

Ireland

100

Simmons, 2016

US

Observational (before and after) Observational (single point) Observational (before and after) Observational (single point) Observational (before and after) Observational (before and after) Observational (single point)

No. SMD in the setting of patients with poor prognosis and surgical emergencies Yes

Mitchell, 2016 Yuen, 2013

US

Legare, 2012 Stacey, 2012

Canada

NR

Canada

55

Observational (before and after)

Von Lengerke, 2011

Germany

63

Observational (before and after)

88

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No. SDM in the setting of prescription talks, specifically HTN No. SDM in the management of upper respiratory infections Yes

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US

68

ro

Author, Year of publication Chesney, 2018

Observational (before and after) Observational (before and after) RCT

No. SDM patients with CKD needing Dialysis No. SDM in the setting of surgical care No. Treatment discussion in 4 Common chronic conditions (diabetes, depression, hypertension and dyslipidemia) No. In the setting of overall communication skills. No. SDM in the intensive care unit No. SDM for the management of upper respiratory infections Yes

Yes

Participants

Outcomes Funding source

Senior general surgery residents

1,3,4,5

NR

Internal Medicine and Medicine/Pediatric Residents Medical students

2, 3, 4

Yes

1,3

Yes

Family and emergency medicine residents Medical students

2

NR

2,3

Yes

Nephrology fellows

1,3

Yes

First year surgical trainees

3

NR

Internal medicine and medicine-pediatrics residents

1,3, 4*,5*

Yes

Anesthesia residents

6

Yes

First year internal medicine residents Family medicine residents

1,3

Yes

6

Yes

Medical residents enrolled in residency focused on oncology or palliative care 2 year medical students

1, 3, 4

Yes

3

NR

Jo

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Outcomes : (1) Satisfaction, (2) Knowledge, (3) Attitudes/Comfort, (4) Practical Skills, (5) Behavior, (6) Patient Outcomes Sullivan, US 37 RCT No. SDM in the setting of opioid Medicine Residents 3 Yes 2012 therapy for non-cancer chronic pain Kalet, 2005 US 76 Observational No. SDM for informed consent Medical Students on surgical 3 Yes (before and after) clerkship Peters, US NR Observational No. Overall setting of Medical students on a 5 NR 2005 (before and after) communication skills longitudinal clerkship Solomon, US NR Observational Yes Third year medical students in 4 Yes 2004 (comparison of the internal medicine clerkship two cohorts) Johnson, US NR Observational No. SDM in the setting of informed First year students College of 2 No 1992 (before and after) consent Osteopathic Medicine *Attempted to measure change in behavior by measuring download of decision aid worksheet (no comparison data); attempted to measuring skills by clinic observation but on 1 visit was observed.

Participants

Chesney, 2018

Senior Surgical residents

Rusiecki, 2017

PGY 3 internal medicine residents and PGY 4 Medicinepediatrics

Sample Women Age SDM teaching Intervention Size (%) (mean/ median) 18 NR NR A 2-hour training intervention included a didactic session, a live demonstration, small-group practice and debriefing. The didactic session involved a 15minute predesigned lecture by faculty covering the unique decisional challenge presented by patients with poor underlying prognosis facing a new life-threatening surgical emergency, the burden of unwanted and no beneficial care, and a case presentation with narrative examples. This was followed by a 10-minute live role-play demonstration by 2 faculty members. The remaining training consisted of small-group practice through case-based role-play facilitated by trained instructors. For this, residents clustered into groups of 2–3 and used predesigned case prompts to practice using the best case/worst case tool. Finally, there was a 15-minute large-group debriefing to discuss the use of Best case/worst case tool.

Teaching strategies used 1, 3, 4, 6, 7

Outcome

36

1,2,6

Knowledge (pre-post questionnaire) Attitudes (pre-post questionnaire) Skills [pre and post evaluation of continuity clinic encounters, using the Observing Patient Involvement in Decision Making (OPTION scale)]

Jo

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Author, Year of publication

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Outcomes : (1) Satisfaction, (2) Knowledge, (3) Attitudes/Comfort, (4) Practical Skills, (5) Behavior, (6) Patient Outcomes Table 2. Participants, intervention and outcomes of the included studies

47

NR

Seven step SDM model presented in a didactic in person session followed by practice with a standardized patient (SP) case. The curriculum was implemented during a 4-week ambulatory rotation. Week 1 participants provided clinical recordings. Week 2 there was a 4-hour didactic in person session including practice with 1 SP and feedback. Week 3 new recordings were obtained. Week 4, two-hour debriefing and small group discussion about barriers, feedback.

Satisfaction (post questionnaire) Attitudes and Confidence (7 point Likert Score before, after and 6 months after the intervention) Skills (Standardized case observation using a 19 points observation form 2 weeks after) Behavior ( 7 point Liker score before, after and 6 months after intervention, plus direct questioning of how many times the principles were use in practice)

Outcomes : (1) Satisfaction, (2) Knowledge, (3) Attitudes/Comfort, (4) Practical Skills, (5) Behavior, (6) Patient Outcomes

NR

NR

One-week elective course. Problem based learning using a HTN case asking the student to identify goals (45 minutes case discussion). Second problem based learning session to discuss relevant publications provided by an internet based learning platform and those found by the student. Followed by a workshop with a tutor, to develop a medication conversation guide, based on SDM concepts. Voluntary participation in simulated prescription talk with a standardized patient. Web based tutorial regarding SDM in the setting of treatment of upper respiratory infections. Initially including in person workshop (2 hour), but for most of the study period the intervention was a web based tutorial and decision aid only. The tutorial included 5 modules and then 6 that should be completed in 2-3 hours. This included videos, exercises and a decision aid. SDM curriculum consisting of 7.5 hours of experiential, small group, online experience and opportunities to learn, practice and share observations. Included practice with a standardized patient and debriefing.

1,2,5,6

Full day annual workshop using didactics, discussion and practice with standardized patients. Learning involved large group session for course introduction, didactics, and observed interview with an invited patient and conclusion. Small group sessions focused on skills practice with simulated patients in a supportive safe environment. Three cases, one case focused on the concept of SDM for a patient with uncertain prognosis and one of the didactic sessions was

1,2,4,6

of

40

ro

Medical students in their 3rd to 5th year

Time of assessment: Post workshop

Cohen, 2016

78

NR

3rd Medical students during a family medicine clerkship 1st year Nephrology fellows

5

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109

ur na

Morrow, 2011

Family and emergency medicine residents

73

26

Jo

Dion, 2016

re

-p

Hauser, 2017

Time of assessment: 4 weeks after the workshop Satisfaction (post questionnaire) Attitudes (qualitative)

NR

54

NR

31 years

Knowledge (pre-post questionnaire) Time of assessment: Post tutorial

1,2,4,5,6

Knowledge (qualitative) Attitudes (qualitative) Time of assessment: Post clerkship Satisfaction (questionnaire) Attitudes (pre-post questionnaire) Time of assessment: Post workshop and 3 months

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Outcomes : (1) Satisfaction, (2) Knowledge, (3) Attitudes/Comfort, (4) Practical Skills, (5) Behavior, (6) Patient Outcomes about SDM. Other focused on bad news, dialysis withdrawal and end of life. Bhatt, 2016 First year 57 47 25 2-hour workshop. The initial portion of the 1,3,4 surgical workshop included a didactic and interactive trainees discussion on the role and models of clinical decision making. This was followed by interactive role play by participants in shared or group decision making. Different scenarios were use: 1) standardized patient journey over multiple time points from diagnosis to death; 2) operative scenario including a video followed by a role play of a anesthetic adverse event and 3) outpatient setting scenario Simmons, 2016 Internal 130 NR NR The workshop lasted 1 hour for PGY-1 residents 1, 3, 4, 6, medicine and 2 hours for PGY 2-4 residents. The workshop 7 and was structured as follows: 1) Sample written case medicine exercise: Residents were asked to read a short pediatrics case of a patient presenting with symptoms of residents moderate depression, answer seven questions about the content of their discussion with the patient about treatment options. 2) Didactic portion: Session leaders gave an overview of SDM, including background and rationale, discussion of risk communication techniques, and presentation of the “6 Steps to Shared Decision Making” framework. 3)Observation: Session leaders hosted a role-play interaction between a patient and a doctor focused on the evaluation and treatment of new-onset moderate depression. 4)Roleplaying: Residents were paired and assigned the role of patient or doctor for a simulated clinical interaction focused on the assessment of a patient with high cholesterol. 5) Debriefing: Open discussion was held with residents about the utility of the Decision Worksheets and any anticipated barriers to using it in clinical interactions.

Attitude (pre-post questionnaire) Time of assessment: Post workshop

Satisfaction (questionnaire) Attitudes (before and after questionnaire) Behavior (frequency of download of decision worksheet) Skills (direct observation in their own practice and feedback by faculty member, only observation was performed) Time of assessment: Post workshop

Patient satisfaction (Modified Four Habits Coding Scheme) Time of assessment: 3 months Satisfaction (questionnaire) Comfort (pre-post questionnaire) Time of assessment: Post workshop

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Outcomes : (1) Satisfaction, (2) Knowledge, (3) Attitudes/Comfort, (4) Practical Skills, (5) Behavior, (6) Patient Outcomes Mitchell, 2016 Anesthesia 30 NR NR Curriculum to address patient’s emotions/ SDM 1,2,4,5,6 residents and setting expectations in the recovery room. 3 simulated patients. 2, 1 hour live teaching and discussion. Observation of simulated scenarios and discussion. And online module, recorded scenarios and reflective open ended questions covering the topics of discussion. Yuen, 2013 First year 29 22 29 Power point module to be reviewed prior to the 1,2,4,5,6 internal retreat followed by a 4-hour communication skill medicine building workshop. The workshop included 1) residents large group didactic session, small group role play with standardized family members, debriefing session. The SDM is based on partnership with mutual exchange of information between the ICU team, patient and family, incorporates the elements of assessing the values/preference, providing information and developing consensus. Legare, 2012 Family 122 73 27-28 Decision+2 consisted of a 2-hour online tutorial 1,5, 7 medicine followed by a 2 hour on site interactive workshop. residents The online tutorial addressed key component of the clinical decision making process about antibiotic treatment for upper respiratory infections. Participants had 1 month to complete. On site interactive workshop aimed to help physicians review and integrate the concepts they acquired during the online training. Online tutorial and workshop included videos, exercises and decision aids to help physicians communicate. Decision aids were available in each of the walk in consultation rooms. Stacey, 2012 Medical 11 45 31 3 hour educational SDM workshop was provided 1,3,4,6 residents by an interprofessional team. The objectives were enrolled in to discuss the relationship between SDM and residency medical decision making, identify key elements of focused on SDM, enhance SDM through role playing, discuss oncology or strategies to facilitate SDM in clinical practice. palliative Role playing was demonstrated by facilitators with care appraisal from residents. The participants engaged in role playing 2 times, in groups of 3 -

Patient outcome (proportion prescribed antibiotics and active role in decision making process) Time of assessment: Post and up to 4 months

Satisfaction (questionnaire) Comfort/Attitudes (questionnaire) Skills on standardize patients (pre-post using the Decision Support Analysis tool)

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Outcomes : (1) Satisfaction, (2) Knowledge, (3) Attitudes/Comfort, (4) Practical Skills, (5) Behavior, (6) Patient Outcomes acting as the patient/physicians or observer. Debriefing exercises were also done. Von Lengerke, 2011 2 year 267 69 23 28-hour course on doctor patient communication 1, 2,3,6 medical skills. Seven session lasting four hours. Didactics students and role play with SP and others. Self-study task and video assisted exercises. The learning objectives consist of basic skill training in taking patient histories, disclosing diagnosis and the use SDM in these context. Sullivan, 2012 Medicine 213 45 NR Collaborative opioid prescribing Education (COPE), 5, 7 residents online interactive module, that focuses on the communication challenges between physician and patients with chronic non cancer related pain. A SDM procedure with collaborative goal setting and careful outcome assessment is presented. Over 100 web pages comprising 6 chapters depict real time clinical interactions between simulated physicians and patients with supporting scientific, policy and clinical material. Basic material about opioid therapy is presented. Two patients are presented where therapy should or should not be prescribed. A summary chapter provides take home points, patient treatment agreements, survival tips and helpful phrases. Kalet, 2005 Medical 121 NR NR The Surgery Clerkship chose to cover 3 1,2,4,6 Students on communication topics: Patient Education, surgical Obtaining Informed Consent/SDM, and Delivering clerkship Bad News. The communication curriculum was implemented on the following schedule. Each session began with a 30-minute lecture to review the relevant knowledge and core communication skills. Then, the group of students, guided by a checklist of behaviorally specific communication skills items, spent 15 minutes analyzing and critiquing a videotaped example of a senior surgeon conducting this communication competency. After a 15-minute small group discussion of the core skills, students were observed conducting the communication skill with

Time of assessment: Post, 1 month and 3 month Comfort (pre-post questionnaire) Time of assessment: Post workshop

Attitudes and behavior (Pre-post measurement using the Physician –patient centeredness using 2 subscale (patient involvement and information sharing) Time of assessment: 45-60 days

Attitudes/Comfort (questionnaire) Time of assessment: post

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Outcomes : (1) Satisfaction, (2) Knowledge, (3) Attitudes/Comfort, (4) Practical Skills, (5) Behavior, (6) Patient Outcomes a standardized patient (SP) and received feedback from peers, the faculty member and the SP (45 minutes). In the final 15 minutes, the teacher led the group in summarizing the lessons learned both about communication skills and the clinical content of the cases. Peters, 2005 Medical 121 53 NR 9 month longitudinal clerkship to integrate topics 8 students in of modern medicine. The syllabus includes SDM. a Students attend the clerkship once a week, in the longitudinal 3rd and 4rd year, they are matched with a primary community based primary care physicians. They care are expected to maintain a longitudinal clerkship relationship with at least one patient and integrate the sever management themes into the care. Provide a final written summary of their experience. Solomon, 2004 Third year 45 NR NR Discussion of participatory decision making, 1,4,6 medical presented in a module by faculty, followed by students in small group discussion and practice using web the internal based case simulations. Participatory decisionmedicine making educational module to enhance skills in clerkship common preventive services and teach students how to inform and involve patients concerning those services. Johnson, 1992 First year 119 NR NR Education program to improve the patient 1, 2, 4, 9 students participation in the informed consent process. College of Informed consent required the development of a Osteopathic communicative relationship with a discussion Medicine focusing on the nature, purpose, risks, and benefits of available treatment alternatives. The program was based on the premise that informed consent can occur only when the physician incorporates a patient’s values and belief into the healthcare decision making process. Lecture, readings, small group discussion, a model videotaped interview conducted by a physician and students videotaped interviews with simulated patients

Behavior (integration of SDM into final notes) Time of assessment: post

Skills on Standardized patient (different times after training using a study checklist) Time of assessment: 4 and 12 weeks after training Knowledge (pre-post knowledge) Time of assessment: post

of

Outcomes : (1) Satisfaction, (2) Knowledge, (3) Attitudes/Comfort, (4) Practical Skills, (5) Behavior, (6) Patient Outcomes

Cohen, 2016 Simmons, 2016 Yuen, 2013 Stacey, 2012

Rusiecki, 2017

-p re

SATISFACTION Proportion of participants that: -rated the shared decision making tool useful -consider their knowledge -confidence increased after the training Likert score (5 worst) evaluating lecture content, small group teaching and assessment of the course

Lecture content Small group teaching Assessment of the course

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Hauser, 2017

Result

Overall course satisfaction, Likert (5 best)

Proportion of participants that rated the course as excellent or very good Overall course satisfaction, Likert (5 best)

90%

Proportion of participants that who met the learning objectives of the course and would recommend the course to others KNOWLEDGE Proportion of correct answers 4 questions of overall SDM knowledge

91%

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Chesney, 2018

Outcome evaluation

Jo

Study

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Table 3. Results Satisfaction and Knowledge

89% 83% 78%

Mean (SD) 1.3 (0.2) 1.4 (0.2) 1.6 (0.5) Mean (SD) 4.8 (0.4)

Mean (SD) 4.5 (0.6)

Before 75%

After 100%*

Definition of equipoise (1 question) 37%

87%

Identify elements of SDM (1 question) Dion, 2016

Frequency of correct answers out of 3 questions regarding SDM

76% 96% Median of 1 correct answer (IQR 0-1) to median of 1 (1-1) after the workshop. The

Outcomes : (1) Satisfaction, (2) Knowledge, (3) Attitudes/Comfort, (4) Practical Skills, (5) Behavior, (6) Patient Outcomes frequency of answering correctly 2 out of the 3 questions did not improved.

of

Frequency of correct answer for each question Before

After

5.5%

5.5%

ro

Knowledge of communication effective communication strategies Clinical situation in which SDM is appropriate

61% Mean Before 7.7

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*Statistically significant difference

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Score on knowledge test

Jo

Johnson, 1992

11.9%

-p

8.3% Assessing patient’s comfort with their decision

84% Mean After 11.4*

Outcomes : (1) Satisfaction, (2) Knowledge, (3) Attitudes/Comfort, (4) Practical Skills, (5) Behavior, (6) Patient Outcomes Table 4. Results Attitudes and comfort Result Attitudes and comfort Baseline Summative score assessing attitudes 16 (1-7 Likert score, 21 best score) Summative score assessing confidence (1-7 Likert score, 21 best score)

14.5

re 3.1

Cohen, 2016

3

15

3.5*

4*

3 3.5 “Referring to SDM I learned that explaining several treatment options and the consecutive shared treatment decision is likely to enhance mutual trust and adherence”

Jo

Hauser, 2017

ur na

Importance of SDM to practice high value care (Single question, 1-4 Likert score, 4 best)

SDM as related to practice of EBM (Single question, 1-4 Likert score, 4 best) Qualitative, “What did I picked up from the course?”

15

Median Before After 2.9 3*

lP

Importance of SDM (Single question, 1-4 Likert score, 4 best)

6 month 16

-p

Rusiecki, 2017 Perceived Confidence with elements of SDM (Single question, 1-4 Likert score, 4 best)

After 15.5

of

Chesney, 2018

Outcome evaluation

ro

Study

Self-reported preparation in communication skills ( 1 question, Likert scale 1 to 5, 5 best)

Before

Eliciting patients goal

2.7(0.7)

4.1(0.6)*

Discussing uncertainty

2.7(0.7)

3.8(0.5)*

Discussing conservative therapy

2.4(0.8)

3.8 (0.7)*

Mean(SD) After

Proportion of participants who had: 76% 74%

Yuen, 2013

Ability to Frame decision with patients to improve quality Comfort with Communication Skills in the ICU (discussing goal of care and treatment preferences in the ICU) (composite Likert questions, 5 best)

100%

Stacey, 2012

Self-reported comfort Obtaining an understanding of the patient/family perspective, values and goals Felt more confident achieving SDM with patients making treatment decision (proportion of participants) Comfort consulting on therapy options with patients (Likert, 5 best)

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Ability to explain SDM

Mean (SD) Before 3.26 (0.88)

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Qualitative

Jo

Von Lengerke, 2011 Morrow, 2011 Sullivan, 2012

After 3.5%*

Physician patient centeredness questionnaire, total and subscale patient involvement and Information sharing Proportion that agrees or strongly agrees that “After the training program, I can collaborate with the patient with chronic non cancer pain to set treatment options”

-p

Simmons, 2016

Before 7%

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Proportion of participants who believe SDM is not important

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Outcomes : (1) Satisfaction, (2) Knowledge, (3) Attitudes/Comfort, (4) Practical Skills, (5) Behavior, (6) Patient Outcomes Qualitative Positive references changes in practice, using SDM Bhatt, Need for SDM in clinical practice Median of 1 with IQR 1-1 before and after 2016 (single question, Likert score, 1 best)

After 3.73 (0.95)

100%

Mean Baseline After 2.6 3.8* “Students gained confidence and competence in the ability to use SDM” No statistically significant difference between control and intervention group

88%

of

Outcomes : (1) Satisfaction, (2) Knowledge, (3) Attitudes/Comfort, (4) Practical Skills, (5) Behavior, (6) Patient Outcomes Kalet, Self-perceived communication skills Improved 46.3% 2005 No change 47.1% Declined 6.6%

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*statistically significant difference

Outcomes : (1) Satisfaction, (2) Knowledge, (3) Attitudes/Comfort, (4) Practical Skills, (5) Behavior, (6) Patient Outcomes Table 5. Results Skills and Clinical Outcomes Result Skills and Behavior After Standardized case observation using a 19 Performed a median of 15 of the 19 expected points instructed observation form behaviors (IQR 13-17)

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Chesney, 2018

Outcome evaluation

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Study

SDM skills in clinical practice, measured using the OPTION score.

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Rusiecki, 2017

94% reported using it at least once in 6 months. 22 % reported using it often, 50% sometimes and 28 infrequently. Mean score Before After 17.3 19.1

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Self-report of using the SDM strategy in clinical practice

Mixed from different participants

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Group difference of 1.84, p value of 0.27).

Integration of SDM on final written report proportion

Stacey, 2012

Quality of SDM using the Decision Support Analysis with a standardized patient.

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Peters, 2016

Total score SDM subscale Mean (SD) Mean (SD) None 27.8 (2.6) 15.2 (1.6) 4 weeks before 30 (2.3) 16.4 (1.7) 12 weeks before 29.2 (2.7) 15.8 (1.5) 4 weeks before 26.7 (2) 14.7 (1.8) CLINICAL OUTCOMES Patient outcome- Proportion of Antibiotic Absolute difference of 18.1% , adjusted RR 0.6 (0.4prescription 0.9) favoring the intervention group Modified Four Habits Coding Scheme for patient satisfaction (1-4 Likert, 4 best) Mean Before After

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Solomon, Study tool including 11 items evaluating 2004 communication during an encounter with a standardized patient (subscale of 6 items related to SDM). (Higher number the better)

Legare, 2012 Mitchell, 2016

Subgroup analysis including only US trained physicians; group difference 5.15, p value 0.01 Integrated – 49% Mentioned 22% Not integrated – 29% (median, range) Baseline 1 month 3 month 3.5 (1-6) 8 (4-10) 4 (2-10) Training

Outcomes : (1) Satisfaction, (2) Knowledge, (3) Attitudes/Comfort, (4) Practical Skills, (5) Behavior, (6) Patient Outcomes Total 3.6 3.8 3.75

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3.55

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Did the anesthesia resident encourage you to be as much involved as you would like in the decision about your anesthesia plan