A structured approach to Shared Decision Making training and assessment of knowledge, attitudes and perception of second year medical students.

Shared decision making (SDM) has been acknowledged in the last decade. Literature has shown that when physicians are engaged in SDM and form a relationship with their patients, there is higher patient satisfaction of care. Moreover, SDM has been reported to improve patient outcomes and clinical measures. Despite this clear benefit of implementing SDM into clinical practice, there is little evidence for including SDM learning into preclinical medical education. We integrated an exercise for second year medical students to practice the steps of shared decision making. In this paper, the quantitative and qualitative results from a survey of medical students following the SDM learning exercise will be discussed. Students were more educated regarding SDM after this exercise and were motivated to use it in their future clinical careers. They also expressed overall positive attitudes towards SDM tools such as decision aids. Feedback to improve this SDM learning experience included the use of standardized patients, and to expand such education to the clinical environment training. This research provides a model of SDM practice integration into medical education. Similar programs can be beneficial for the development of SDM and other interpersonal skills.

Introduction

The patient-physician relationship has evolved from a paternal model into a collaborative shared decision-making (SDM) relationship. Shared decision making (SDM) is an approach where clinicians and patients make decisions together based on patients’ preferences and values while utilizing the best available evidence. SDM has been associated with higher patient satisfaction of care and enhanced performance on clinical measures [1,2]. Several barriers to the practice of SDM include the time constraints, physicians’ lack of understanding of the process of SDM and clinical workflow limitations [3].

Integration of SDM courses into undergraduate medical education has been effective in improving medical students’ skills, confidence, and attitudes regarding SDM [3]. Most of such trainings are delivered in the third year of medical school during clerkships and how medical schools deliver and integrate such training into educational curricula is less clear [3,4].

We describe our approach to integrate SDM introduction, training, and assessment in to second year medical students’ education.

Our SDM session included an introductory didactic teaching followed by a role-play exercise and survey questionnaire. The didactic segment focused on AHRQ’s (Agency of Healthcare Research and Quality) SHARE approach and included the slides and videos from the training module 1 [5].

Subsequently, medical students performed role-play exercises in the clinical skills area of the medical school Simulation Center. The role play was conducted amongst the students within their established case-based learning small groups. Patient, physician and observer triads of students participated in the exercise with different clinical scenario scripts (see Appendix 1) and practiced performing SDM. The observer student immediately outside the simulation clinic room graded the physician student utilizing a rubric based on SHARE model (see Appendix 2). The remaining students in the small group and the clinician faculty group leader also observed the interaction live via video, completed the rubric, and discussed the interaction. Then the students switched roles; the students watching remotely performed the SDM skills exercise, while the others watched the live video feed with the faculty member. The scenarios were different in each encounter completed. A total of 103 students participated in the exercise. Twelve faculty small group leaders facilitated the discussion amongst the small group students while observing the exercise and created debrief opportunities. A ten-item post-exercise survey questionnaire assessed students’ knowledge (four questions) and attitudes (four questions) about SDM and their feedback on the content delivery and practice (two questions) with the option to add qualitative comments (see Appendix 3). The survey response rate was 100% as the survey questionnaire was part of the exercise.

96% of the students answered the SDM knowledge questions correctly. 81% agreed or strongly agreed that the session was helpful in adding to their knowledge and practice of shared decision making. Student feedback included consideration of Standardized Patients in future. 96% of the students agreed that performing shared decision making is realistic regardless of time constraints and 84% felt that SDM can be done with patients regardless of their level of education and comfort in discussing medical treatment options. 100% of our student participants agreed that having resources which summarize the risks and benefits of treatment options such as decision aids will be helpful in successful implementation of SDM.

In summary, following SDM training and exercise, our students felt more knowledgeable with increased comfort regarding the practice of SDM and were motivated to use it in their future career. The patient’s education level and time constraints were not of great concern to the students. Feedback to improve this SDM learning experience included the use of Standardized Patients, and to expand such education in the clinical environment. Our students favored a combination of didactics and practical exercise for their SDM education. These findings can inform both undergraduate and graduate medical education curricula as we strive to enhance teaching and experience of our learners in incorporating patient engagement into clinical decision making. As the patient population in the USA becomes increasingly diverse, performing SDM with all patients regardless of their education level or understanding while keeping their preferences and values in mind has the potential to enhance patients’ trust in the health care system, increase uptake of care recommendations and improve clinical outcomes.

This project has several limitations. Didactic component of our training was brief with selective discussion of one of AHRQ’s SDM modules. We did not use a comparison group or pre and post analysis and we did not replicate similar training during clinical years or assess the retention of SDM knowledge and skills.

Future direction of our project includes expansion of similar exercise into clerkship curricula to reinforce the skills and practice. Familiarity and comfort with utilization of decision aids are also of paramount importance. Clinical decision aids have been shown not only to increase patient knowledge, but also to increase the level of shared decision making without lengthening the duration of the encounter [6]. Thus, simulation exercises built around performing SDM while utilizing decision aid would be a great addition to our SDM curriculum. Incorporation of SHARE rubric in to Observed Structured Clinical Exercises will be an important step as well. Voluntary translation of medical documents into plain language by medical students led to higher expression of shared decision-making skills in simulated physician-patient encounters [7]. Such novel ways to enhance learners’ knowledge and comfort in SDM should also be researched. Systematic review of SDM education studies indicated that another important area of future research is the impact of SDM education on students’ behaviors and patient outcomes [8].

In conclusion, a structured approach to enhance medical students’ ability, interest, practice and comfort in taking patients’ perspective by incorporating SDM training and assessment in the medical education curriculum has the promise of promoting patient engagement in health care decisions and quality of care delivered.