Educational interventions for shared decision making and the role of patient agency:  A Systematic Review

Introduction

Shared decision making is critical to patient-centered care, and yet there is limited consensus on how to most effectively teach it to health professionals. Although numerous educational interventions have been developed, many have not been methodically studied nor described in the literature^1,2. In a recent systematic review of published studies, Muller et al. found great variation in the interventions, outcome measures, and conclusions of the 41 included articles³. Because their analysis did not allow matching training components with outcomes, conclusions were limited for the most effective strategies, further, they noted that most of the published studies reported on provider-reported outcomes over observed or patient outcomes³. Because shared decision making is a collaborative process in which the patient and provider co-create a decision based on the patient’s preferences and values in addition to scientific evidence, we propose that in-depth analysis of studies with patient-reported outcomes may help us better identify successful approaches and determine gaps in pedagogy.

Focusing on studies with patient outcomes may also allow for closer examination of the role of agency in shared clinical decisions. We suggest that shared decision making requires not only a patient with sufficient agency to participate in the collaborative process, but a clinician whose actions enhance relational agency in the encounter. One commonly cited definition of agency, by Giddens, is an individual acting intentionally, with the capacity to act on his or her intentions, and having the power to create a new event or intervene in an existing event⁴. According to Giddens, individual agency can be shaped, facilitated, or constrained by social structures. The clinical encounter is such a social structure, made up of the actions of the physician, the clinical and patient support tools, the culture, environment, and expectations. Relational agency has been defined as “the capacity to work with others to expand the object that one is working on by bringing to bear the sense-making of others”⁵. By examining relational agency of a physician and patient dyad, we can better understand how a shared decision can be accomplished.

Despite the apparent importance of agency to shared decision making, it is unclear if educational interventions address the roles of patient and relational agency. Thus, we sought to answer the questions: How is shared decision making taught to physicians and, secondarily, in what ways, if any, is the concept of agency addressed in these educational efforts?

Methods

We conducted a systematic review of studies evaluating educational interventions for physicians that aimed to increase shared decision making in the clinical encounter, as measured by patient-level outcomes. Our review followed guiding principles of conducting systematic reviews in medical education⁶ and is reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses⁷. (See PRISMA Checklist: https://zenodo.org/record/5029150#.YNTs6ndKicY)⁸.

Results

Our search yielded 2879 articles after duplicates were removed. After title/abstract review, we identified 34 for full-text review, of which we excluded 8. We also reviewed reference lists of 10 articles marked as key background/review articles and the 26 remaining articles. In total, we identified 26 articles^13–38, describing 17 unique studies meeting the inclusion criteria for our review. Figure 1 diagrams our review process. In this section, we first report study characteristics and describe the educational interventions. We then turn attention to elements of shared decision making and agency which we have mapped to CHAT.

Figure 1. Literature Search and Study Selection Process.

Literature search and study selection process for a systematic review of the literature, published between January 2000 and January 2020, on educational interventions for health professionals that aimed to increase shared decision making in the clinical encounter, as measured by patient-level outcomes. The study followed the PRISMA guidelines for conducting a systematic review.

Table 1 includes characteristics of the included studies. From the included studies, 14 (82%) were randomized controlled trials (RCT), with the majority characterized as cluster RCTs. Six studies were conducted in Germany, four in the United States, three in the Netherlands, and the remainder in Canada (2), the United Kingdom (1), and Mexico (1). Most studies (n=12; 71%) were conducted with primary care physicians and the remainder were specialists or unspecified. All studies received external funding and were found to be of high quality based on MERSQI scores ranging from 13.5 to 18.

Discussion

We identified and reviewed a broad range of educational interventions around shared decision making. As in previous reviews^1–3, all included studies described multicomponent interventions and it is difficult to draw conclusions about effectiveness of any individual component. However, by focusing on patient outcomes, we reveal common elements among many of the studies, including use of tools such as decision aids, small group discussions, and role play or practice with simulated patients, which may be critical for shared decision making. None of the included studies explicitly addressed patient or relational agency.

Based on our analysis, role play and practice with simulated patients were key elements of effective interventions. Like many educational interventions aimed at improving physician communication skills, role play, and the use of simulated patients provide opportunities for physicians to practice those competencies. An umbrella review that examined effective educational programs for teaching physicians’ communication skills found that the interventions were effective if they were at least one day long, learner-centered (practical), and focused on skills practice⁴¹. Among specific strategies, role play with simulated or real patients, feedback and small group discussions were found to be effective⁴¹. The authors of the umbrella review reported that interventions were often poorly described and varied greatly, most lacked theoretical underpinnings, and relative efficacy was difficult to ascertain because many components were combined⁴¹. One of the included reviews specifically examined the use of simulated patients and/or role play in 23 studies and concluded that more studies report improvement in communication skills when practice has taken place; the single study that compared role play with simulated patients showed no difference in extent of improvement⁴². Although limitations included multicomponent interventions, variable outcomes, small study size, and potential selection bias in some studies, the three studies considered higher quality demonstrated better outcomes when simulated patients and/or role play were utilized⁴².

Although the multicomponent nature of the included interventions in this review prevents us from teasing out the specific impact of role play and/or simulated patients, the studies that included these components demonstrated improvements in shared decision making outcomes. In addition to the importance of communication competencies in making shared decisions, we propose that practice and feedback might also provide the social context required to develop and maintain physician behaviors that bolster patient engagement and partnership in the complex shared decision making process. Although relational agency was not mentioned explicitly, these interactive interventions may enhance the physician’s comfort with relational agency. Role play, in particular, may be well suited to facilitate relational agency. As Lane and Rollnick wrote in their 2007 study: “. . . trainees can get additional knowledge by experiencing the role of the patient”⁴².

We did not identify any studies that explicitly addressed patient or relational agency, either in the design of the intervention or in reported outcomes. The study by Bieber et al. allowed us to retrospectively consider how relational agency may be emphasized in educational interventions and how CHAT could be utilized in the analysis of an educational intervention^18,19. But we must be clear that this was our interpretation of a study and not the authors’ explicit intent. Given our finding that the majority of studies included role play or simulated patients and considering that these approaches most logically allow the introduction and development of the concept of relational agency between patient and physicians, we would recommend consideration of this area for future study. Street et al. addressed the issue of how clinician-patient communication can directly and indirectly impact health outcomes, by empowering patients to be active agents in their health: “Clinicians can facilitate patient involvement in the decision making process by helping patients actively seek information, clarify treatment goals, and express concerns and feelings”⁴³. Applying the CHAT framework to studies of shared decision making interventions will allow investigators to examine how well the intervention addresses tensions in the simulated clinical encounter and how physicians learn to engage patients in decisions, potentially leading to expansive learning over time.

Consideration of relational agency may be important to successful shared decision making and should be included in development of future educational interventions. Focused on relational agency, Edwards and D’Arcy studied young bilingual pupils teaching a foreign language to student teachers. Similar to shared decision making between a physician and patient, “teaching was . . . seen as joint action between pupils and student teachers on the shared object of the learners’ communicative competence, using some fairly traditional pedagogic tools”⁴⁴. The investigators also found that the sessions became more interactive and responsive; the authors stated: “. . . the concept of relational agency, embedded within the idea of a classroom as an open-ended learning zone is a useful way forward. Its particular strength lies in the emphasis it places on the need for learners to develop the capacity to both seek and give support in joint action on the object of activity to expand mutual understandings of the object”⁴⁴. We can envision a similar application to shared decision making, in which role play and simulated patients give the physician learners an opportunity to learn from the interaction with the “patient”; similarly, over time, physicians and patients learn from each other how to reach the shared object of shared decision making. Expansive learning can begin with an educational intervention that has development of relational agency between patient and physician as a central theme.

There do not appear to be well-accepted instruments or tools to evaluate or measure patient or relational agency; therefore, studies that address the role of agency in shared decision making should include a qualitative component. The use of qualitative analysis within the Bieber study design provided a rich example of the potential impact of the intervention on patient agency¹⁸. Our use of CHAT in this review demonstrates its potential as a future framework to analyze the role of agency in studies of shared decision making and to suggest potential areas for future research. Specifically, the tensions between each of the components of an activity system shed light on the complexity of shared decision making. Furthermore, the more complex tensions between two activity systems are also worth investigating.

In order to characterize studies of shared decision-making educational interventions and identify those that address patient agency, we included only studies that reported patient outcomes. One benefit of our approach, besides answering our research questions, was that many of our studies scored high on quality ratings. Other potential reasons for the higher MERSQI ratings are that the majority of the studies were RCTs and, in particular, many of the included studies used previously validated instruments to report on outcomes, such as the OPTION and Roter scales.

However, by focusing on actual patient outcomes, our approach excluded articles describing medical students or other trainees who do not see patients independently; all of the interventions involved physicians who cared for patients independently (i.e., attending physicians, fellows, and residents). Another limitation was that, while the majority of studies were RCTs, making them methodologically strong educational studies, they often did not include qualitative analyses that may have provided more insight into the role of agency. Finally, despite our best efforts to conduct a comprehensive search, it is possible we inadvertently missed articles.

Conclusions

Educational interventions to teach shared decision making to physicians commonly include decision aids, role play, and/or simulated patients, and have had a positive impact on a range of patient outcomes. Explicit instructional design around individual and relational agency is absent from educational interventions for shared decision making. Using CHAT can highlight the role of agency and identify tensions that could be included in the design and development of training programs. Future research and development of instructional strategies should consider the complexity inherent in co-constructing decisions.

Educators should consider utilizing multicomponent interventions to teach shared decision making, including role play and/or simulated patients and should ensure health professionals are familiar and can effectively engage patients using decision aids. Although formal educational programs around facilitating patient agency have not been developed, clinicians should look for opportunities to encourage patients to actively seek information and should inquire about patients’ preferences and treatment goals.

Data availability statement