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Assessment of Medical Students’ Shared Decision-Making in Standardized Patient Encounters

Assessment of Medical Students’ Shared Decision-Making in Standardized Patient Encounters Assessment of Medical Students’ Shared Decision-Making in Standardized Patient Encounters 1 2 3 3 Karen E. Hauer, MD , Alicia Fernandez, MD , Arianne Teherani, PhD , Christy K. Boscardin, PhD , and George W. Saba, PhD 1 2 Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA; Department of Medicine and Office of Medical Education, University of California, San Francisco, San Francisco, CA, USA; Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, USA. KEY WORDS: shared decision-making; medical students; standardized BACKGROUND: Shared decision-making, in which patient encounters. physicians and patients openly explore beliefs, ex- J Gen Intern Med 26(4):367–72 change information, and reach explicit closure, may DOI: 10.1007/s11606-010-1567-7 represent optimal physician–patient communication. © The Author(s) 2010. This article is published with open access at There are currently no universally accepted methods Springerlink.com to assess medical students’ competence in shared decision-making. OBJECTIVE: To characterize medical students’ shared decision-making with standardized patients (SPs) and determine if students’ use of shared decision-making BACKGROUND correlates with SP ratings of their communication. DESIGN: Retrospective study of medical students’ Medical students must achieve communication skills compe- performance with four SPs. tence to provide effective care to patients. Communication skills PARTICIPANTS: Sixty fourth-year medical students. have been linked to patient outcomes such as satisfaction and 1,2 MEASUREMENTS: Objective blinded coding of shared adherence . Doctor–patient communication can entail many decision-making quantified as decision moments (explo- behaviors including establishing rapport, eliciting the patient’s ration/articulation of perspective, information sharing, perspective, and engaging in shared decision-making. explicit closure for a particular decision); SP scoring of Shared decision-making has been promoted by experts in communication skills using a validated checklist. clinical communication as an ideal model of physician– RESULTS: Of 779 decision moments generated in 240 patient communication. Shared decision-making is based encounters, 312 (40%) met criteria for shared decision- on the premise that the best medical decision for an making. All students engaged in shared decision-making individual patient incorporates the patient’spreferences in at least two of the four cases, although in two cases 5% and values through a process in which the physician and and 12% of students engaged in no shared decision- patient openly explore beliefs, exchange information, and 3–8 making. The most commonly discussed decision mo- reach explicit closure. Advocates of shared decision-making ment topics were medications (n=98, 31%), follow-up believe it provides a better medical encounter experience than either visits (71, 23%), and diagnostic testing (44, 14%). paternalistic (physician-directed) or consumerist (patient-directed) 7,9 Correlations between the number of decision moments decision-making styles. Patients who experience their preferred in a case and students’ communication scores were low decision-making style with their primary physicians are more likely 10,11 (rho=0.07 to 0.37). to perceive those physicians as providing excellent care. Some CONCLUSIONS: Although all students engaged in some studies show that shared decision-making improves patient satis- 12–14 shared decision-making, particularly regarding medical faction, adherence to medications, and health outcomes. interventions, there was no correlation between shared Assessing shared decision-making behavior may not be simple, decision-making and overall communication compe- for either practicing physicians or students. It has been operationa- tence rated by the SPs. These findings suggest that SP lized as a set of measurable communication behaviors incorporating 4,7,15 ratings of students’ communication skill cannot be patients’ preferences and values. There are three domains of used to infer students’ use of shared decision-making. behaviors common to the shared decision-making process: 1) Tools to determine students’ skill in shared decision- exchange of feelings and beliefs; 2) exchange of information about making are needed. the disease, its diagnosis and treatment; and 3) reaching clo- 4,7,15 sure. In a qualitative study examining the relationship of Electronic supplementary material The online version of this article shared decision-making to patient satisfaction, the presence or (doi:10.1007/s11606-010-1567-7) contains supplementary material, absence of shared decision-making in a given encounter did not which is available to authorized users. consistently correlate with patients’ satisfaction with their phy- Received June 11, 2010 sicians’ communication and relationship-building behavior, sug- Revised September 14, 2010 gesting that shared decision-making is only one of several facets Accepted October 25, 2010 Published online November 25, 2010 of communication that influence overall patient satisfaction. 367 368 Hauer et al.: Medical Students’ Shared Decision-Making JGIM Medical students’ competence in communication skills is conditions likely to prompt decision-making opportunities often assessed through the communication component of regarding disease management or behaviors. (Appendix 1, clinical practice examinations in which trained standardized available online) For shared decision-making to occur, one 4,23 patients typically assess students’ communication competence necessary prerequisite is a decision with multiple options . using a communication behaviors checklist. These ratings Standardized patients participated in 17 hours of training over may or may not capture medical students’ use of shared five sessions. Two different standardized patients portrayed the decision-making. For instance, communication behaviors such hypertension case and three portrayed each of the other three as building rapport, expressing empathy, and using body cases. The trainer assessed the standardized patients for language may occur in the absence (or presence) of active consistency of portrayal and checklist accuracy during training patient involvement in decision-making. Nonetheless, there is and the exam. a growing need to assess medical student engagement in shared The CPX case checklists used by the standardized patients decision-making behavior with their patients to understand how included seven communication items (listening, rapport building, trainees develop this skill. Physician belief in the benefits of professional demeanor, and addressing the patient’s perspective shared decision-making and motivation to engage in shared and needs) based on the Common Ground checklist. This decision-making are crucial facilitators of this behavior ,and it checklist was previously shown to have high reliability (rho=> is important to impart these attitudes during the formative 0.80) when completed by trained raters and high correlation with 20 24 stages of training before practice patterns are established. global ratings of communication by faculty experts (r=0.84). However, with their less mature clinical skills, students may be Standardized patients scored the communication items from 0 to more challenged than physicians by the time constraints of 1.0 on a six-point scale (0, 0.2, 0.4, 0.6, 0.8, 1.0, as defined in ambulatory encounters, which are a major barrier to shared Appendix 2, available online), with total scores reported as decision-making. We designed this study to characterize the percentages (maximum 100%). nature and amount of medical students’ shared decision- Shared decision-making coding: Four investigators (KEH, AF, making and to determine if ratings of general communication AT, GS) coded shared decision-making using a coding manual correlate with students’ use of shared decision-making. (Appendix 3, summary available online) and coding worksheet (Appendix 4, available online) from an instrument used to code physician–patient encounters. The worksheet includes checkboxes for decision moment identification and each of the METHODS key dimensions of shared decision-making within a single decision moment: exploration/articulation of perspective (beliefs, values), information sharing, and explicit closure, each of which could be done by the student, standardized patient, or Design. This was a retrospective observational study of medical both. In contrast to some other published shared decision- 6,11,17 students’ performance with standardized patients. The making scales, we captured both the student physician’s Institutional Review Board approved the study. sharing of beliefs and values and the students’ responses to information from the patient. A single worksheet was used for each decision moment, which begins when a suggestion is made Subjects and Setting. After the third-year core clerkships, all to change behavior or consider medical therapy or testing. Each University of California, San Francisco (UCSF) students are dimension was marked as present or absent for each decision required to take the Clinical Performance Examination (CPX). discussed by the student and standardized patient; each The CPX is an eight-station comprehensive standardized dimension was attributed to the student or patient only once per patient examination developed by the eight medical schools decision moment. comprising the California Consortium for the Assessment of Examples of shared decision-making decision moment Clinical Competence. Each CPX encounter lasts 15 minutes discussions between students and standardized patients are and is videotaped. After each encounter, standardized patients shown in Text box 1. There was no maximum number of decision complete a criterion-based checklist evaluating students’ moments per case; it was also possible for an encounter to have history taking, physical examination, communication and none. Each of the 240 encounters was coded by two coders, and information sharing skills. Checklist accuracy by the reconciled by consensus discussion between the two coders, or consortium’s standardized patients exceeds 95%. with other coders in the event of discrepancy, which was rare. A total of 143 UCSF medical students comprising the class of 2006 participated in the May–June 2005 CPX. The class of 2006 was 63% female. The self-described racial makeup of the class Analysis. For analysis, we defined shared decision-making as a was 48% White, 33% Asian, 3% Black, 2% Native American, 6% decision moment that included at least four of the possible ten other race, 2% unknown, and 6% multirace. We used a random decision-making elements (in addition to decision identification) number generator to select a 60-student probability sample for on the worksheet (Appendix 4, available online) in which one of the study. This sample size (n=60) gave adequate (80%) power to the four was closure of the decision by the patient. Inclusion of at detect correlations of 0.35 and outstanding power (99%) to detect least four elements ensures participation by both student and correlations of 0.5 or larger. All CPX encounters were video- patient with presence of essential domains of shared decision- recorded as part of usual exam procedure. Videotapes of the four making (exchange of feelings and beliefs, exchange of study cases from the 60 randomly selected students were information, and closure). This cutoff is similar to that used in transcribed for analysis. prior literature, with a slightly lower cutoff due to students’ earlier Communications skills cases and rating instrument: For this point in training than practicing physicians. Closure of the study, we selected four CPX cases that highlighted medical decision by the patient is essential to determine whether shared JGIM Hauer et al.: Medical Students’ Shared Decision-Making 369 Example 1: Decision Moment regarding diet modification Speaker Comment Decision moment element Student But always, you know, you're out to a Decision identification restaurant to not order just the thing that AND on the menu that looks the best. Exploration/articulation of perspective –student offers Patient Right. Student But once in a while, you know, try to Information sharing – order a salad. Try to decrease the fat. student offers That'll help your cholesterol a lot. Patient Yeah. I know that. It's just hard to do. Exploration/articulation of perspective – patient offers Student I know. Exploration/articulation of perspective – student offers Patient [It's like] you open the menu, and you Exploration/articulation of say, ‘Well, I'll get the steak today and perspective – patient offers the chicken tomorrow.’ Student Right. Keep it in mind because this is Information sharing – something that's important to your health student offers in the future. You know, cholesterol and diabetes are two of the major risk factors for heart disease. And heart disease is the number one killer. Patient Mm-hmm. Student Okay. So we need to keep these under Information sharing – control to protect you for the future. student offers Patient Okay. Got a deal. Closure – patient Student Okay. Closure – student Patient All right. Closure – patient Example 2: Decision Moment regarding diagnostic testing Patient So you don't think I need anything, like a Decision identification CAT scan or anything like that? AND Information sharing – patient elicits Student I actually don't think so. The percent Information sharing – chance of you having a tumor in there is student offers like, less than 1 percent, especially with a completely normal exam. You haven't had any symptoms until right now. And those are kind of the reasons why. Patient Okay. Student Does that, does that sound reasonable? I Exploration/articulation of don't want to pressure you into thinking perspective – student elicits one way or the other. Of course I'm open and offers to your concerns. But that's kind of just where I'm thinking right now. Patient Okay. Closure – patient Student Okay? Exploration/articulation of perspective – student elicits Patient All right. Closure – patient Text box 1. Shared Decision-Making Decision Moment Examples 370 Hauer et al.: Medical Students’ Shared Decision-Making JGIM decision-making has occurred; without closure by the patient, Association Between Communication Scores the physician may make decisions unilaterally. Traditionally, and Shared Decision Making physicians are more vocal about closure than patients (e.g., ‘we The mean (standard deviation) communication scores out of a will change your medicine’; ‘I want you to monitor your glucose’); maximum of 100 for the 60 students were: diabetes 68.71 patients’ verbalization of closure ensures their agreement. (7.86), headache 69.57 (7.99), hypertension 61.23 (6.81), and We calculated the total number of decision moments overall teen 69.19 (8.79). The correlations between number of and by decision topic. The key outcome used in correlation shared decision-making moments in a case and the respec- analyses was the number of decision moments with ≥4 tive communication score from the standardized patient elements as defined above. We used Spearman rank were low for three cases: diabetes (rho=0.07; 95% confi- correlations, a non-parametric test, to examine the association dence interval -0.109, 0.32), headache (rho = 0.10; -0.16, between number of decision moments with ≥4 elements and the 0.34), and teen (rho=0.08; -0.18, 0.33), and moderate for CPX communication score for each case. Data analyses were the hypertension case (rho=0.37; 0.13, 0.57). performed using SPSS 17.0 (SPSS, Inc., Chicago). DISCUSSION RESULTS In this analysis of student-standardized patient encounters in The 240 encounters from the 60 students generated 779 a high-stakes clinical skills examination, we found that, decision moments across all four cases. Of the 779 decision although all students engaged in some shared decision- moments, 483 (62%) had shared decision-making scores of making with their patients, the number of shared decision- four or greater, 390 (50%) included patient closure, and 312 making moments per case had limited correlation with the (40%) had both. These 312 comprised the shared decision checklist communication score rendered by standardized moment dataset. The number of decision moments per student patients. This finding implies shortcomings in existing mea- across all four cases ranged from 6.00 to 23.00; the mean sures of communication skills in that shared decision-making (standard deviation) was 13.98 (3.07). Considering each case is independent of other aspects of communication, such as individually, the number of decision moments was: diabetes students’ communication behaviors and patients’ perceptions 3.93 (2.25), headache 2.15 (1.13), hypertension 3.87 (1.23), of rapport. Shared decision-making seems to involve additional and teen 2.97 (1.22). aspects of the interaction and may challenge students working All students engaged at least once in shared decision- with standardized (or actual) patients to collaborate in care making (i.e., included at least four elements, one of which planning in ways not rewarded in typical communication was patient closure) in both the hypertension and teen cases. checklists. In contrast, for the other two cases, 5% (diabetes) and 12% CPX scores may reflect meaningful aspects of communica- (headache) of students did not engage in any shared decision- tion that differ from shared decision-making. Although shared making. decision-making is often cited as an ideal model of physician– As shown in Table 1, among the 312 shared decision patient communication, our findings of limited correlation moments, the most commonly discussed topics were medica- between shared decision-making and overall communication tions (n=98, 31%), follow-up visits (71, 23%), and diagnostic scores from standardized patients are consistent with prior testing (44, 14%). Lifestyle changes such as exercise (30, 9%) literature showing that patients’ preferences for decision- and diet (27, 10%) were discussed less frequently using shared making style are complex and variable. Approximately one third 10,15,25 decision-making. of patients may prefer a different style, particularly based Table 1. Topics of Shared Decision-Making Decision for 4 Standardized Patient Cases CASE Diabetes Headache Hypertension Teen TOTAL Decision Moment N% N % N % N% N % Adjust medications 25 8.0% 38 12.2% 35 11.2% 98 31.4% Follow-up appointment with physician 12 3.8% 5 1.6% 50 16.0% 4 1.3% 71 22.8% Get more tests 26 8.3% 7 2.2% 11 3.5% 44 14.1% Exercise 15 4.8% 15 4.8% 30 9.6% Diet change 16 5.1% 11 3.5% 27 8.7% Self-monitor glucose 14 4.5% 14 4.5% Refer to ancillary health professional 8 2.6% 1 0.3% 1 0.3% 10 3.2% Refer to another physician 6 1.9% 1 0.3% 7 2.2% Engage in safer sex 5 1.6% 5 1.6% Self-monitor blood pressure 3 1.0% 3 1.0% Talk to patient’s mother 3 1.0% 3 1.0% TOTAL 96 30.8% 70 22.4% 122 39.1% 24 7.7% 312 100.0% Sixty students each completed four cases (240 encounters), during which a total of 312 decision moments occurred JGIM Hauer et al.: Medical Students’ Shared Decision-Making 371 on their medical conditions. Other aspects of communication, In this study of medical students’ shared decision-making such as empathy and rapport, may be valued more highly than with standardized patients, we found minimal correlation decision-making style. between the frequency of shared decision-making and stan- Our results suggest that commonly used standardized dardized patients’ ratings of overall communication. All stu- patient checklists could be modified to include explicit assess- dents engaged in some shared decision-making, although they ment of shared decision-making behaviors. Our work extends focused their discussions on physician-oriented topics rather that done using the OPTION scale , another scale for assessing than patient self-management. Further study is needed to shared decision-making, in student-standardized patient determine how medical students can best engage their encounters, in which capturing balanced measures of both patients in collaborative care, and how educators can measure persons’ contributions is important in student assessment. that engagement with psychometrically sound instruments. Assessing students’ shared decision-making in standardized That knowledge would enhance both medical education and patient examinations raises practical challenges including patient care. requirements for detailed coding of interactions and extensive standardized patient training. While this task is daunting, the evidence for shared decision-making as a preferred communi- Acknowledgements: The authors thank Kathleen Kerr and Suzy 27–31 Hull for their assistance with shared decision-making coding, cation strategy is growing and the applications expanding. Joanne Batt for data management, and Steven Gregorich and To address feasibility concerns, efforts could focus on a few key Patricia S. O’Sullivan for expert advice. components of shared decision-making while still capturing both patient and physician perspectives on decision-mak- 32,33 ing. Alternatively, assessing shared decision-making in Conflict of Interest: None disclosed. formative standardized patient examinations might allow for Funding: Funding for this project was provided by Stemmler meaningful feedback from patients to students without Medical Education Research Fund of the National Board of Medical necessitating high checklist reliability. Examiners. Dr. Fernandez was also partly supported by the Arnold It is encouraging that, in our study, all students engaged in P. Gold Foundation Professorship award. some shared decision-making. Of the decision moments, almost half met our criteria for shared decision-making. This percent- Open Access: This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which per- age is comparable to findings with actual physician–patient mits any noncommercial use, distribution, and reproduction in any encounters, in which, using a slightly different threshold, half of medium, provided the original author(s) and source are credited. decision moments qualified as shared decision-making. Our results also provide insights into students’ predilection to Corresponding Author: Karen E. Hauer, MD; Department of emphasize biomedical rather than lifestyle topics while counsel- Medicine, University of California, San Francisco, 505 Parnassus Ave, M1078, Box 0120, San Francisco, CA 94143-0120, USA ing patients with a variety of clinical presentations. We found (e-mail: karen.hauer@ucsf.edu). that students used shared decision-making more when dis- cussing medical interventions, such as medications and tests, rather than patient self-management strategies. Prior studies have shown low rates of physician counseling about lifestyle REFERENCES 35,36 modification. Students may lack knowledge about the 1. Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician– benefits of lifestyle modification, or, more likely, about how to patient communication: the relationship with malpractice claims among engage patients to implement these changes. These findings primary care physicians and surgeons. JAMA. 1997;277:553–559. 2. Stewart M, Brown JB, Donner A, et al. The impact of patient-centered suggest that medical school curricula and assessments should care on outcomes. J Fam Pract. 2000;49(9):796–804. increase their focus on lifestyle modification; students should 3. Elwyn G, Edwards A, Kinnersley P. 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Patient Educ Couns. 2006;60(3):301–312. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of General Internal Medicine Pubmed Central

Assessment of Medical Students’ Shared Decision-Making in Standardized Patient Encounters

Journal of General Internal Medicine , Volume 26 (4) – Nov 25, 2010

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Abstract

Assessment of Medical Students’ Shared Decision-Making in Standardized Patient Encounters 1 2 3 3 Karen E. Hauer, MD , Alicia Fernandez, MD , Arianne Teherani, PhD , Christy K. Boscardin, PhD , and George W. Saba, PhD 1 2 Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA; Department of Medicine and Office of Medical Education, University of California, San Francisco, San Francisco, CA, USA; Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, USA. KEY WORDS: shared decision-making; medical students; standardized BACKGROUND: Shared decision-making, in which patient encounters. physicians and patients openly explore beliefs, ex- J Gen Intern Med 26(4):367–72 change information, and reach explicit closure, may DOI: 10.1007/s11606-010-1567-7 represent optimal physician–patient communication. © The Author(s) 2010. This article is published with open access at There are currently no universally accepted methods Springerlink.com to assess medical students’ competence in shared decision-making. OBJECTIVE: To characterize medical students’ shared decision-making with standardized patients (SPs) and determine if students’ use of shared decision-making BACKGROUND correlates with SP ratings of their communication. DESIGN: Retrospective study of medical students’ Medical students must achieve communication skills compe- performance with four SPs. tence to provide effective care to patients. Communication skills PARTICIPANTS: Sixty fourth-year medical students. have been linked to patient outcomes such as satisfaction and 1,2 MEASUREMENTS: Objective blinded coding of shared adherence . Doctor–patient communication can entail many decision-making quantified as decision moments (explo- behaviors including establishing rapport, eliciting the patient’s ration/articulation of perspective, information sharing, perspective, and engaging in shared decision-making. explicit closure for a particular decision); SP scoring of Shared decision-making has been promoted by experts in communication skills using a validated checklist. clinical communication as an ideal model of physician– RESULTS: Of 779 decision moments generated in 240 patient communication. Shared decision-making is based encounters, 312 (40%) met criteria for shared decision- on the premise that the best medical decision for an making. All students engaged in shared decision-making individual patient incorporates the patient’spreferences in at least two of the four cases, although in two cases 5% and values through a process in which the physician and and 12% of students engaged in no shared decision- patient openly explore beliefs, exchange information, and 3–8 making. The most commonly discussed decision mo- reach explicit closure. Advocates of shared decision-making ment topics were medications (n=98, 31%), follow-up believe it provides a better medical encounter experience than either visits (71, 23%), and diagnostic testing (44, 14%). paternalistic (physician-directed) or consumerist (patient-directed) 7,9 Correlations between the number of decision moments decision-making styles. Patients who experience their preferred in a case and students’ communication scores were low decision-making style with their primary physicians are more likely 10,11 (rho=0.07 to 0.37). to perceive those physicians as providing excellent care. Some CONCLUSIONS: Although all students engaged in some studies show that shared decision-making improves patient satis- 12–14 shared decision-making, particularly regarding medical faction, adherence to medications, and health outcomes. interventions, there was no correlation between shared Assessing shared decision-making behavior may not be simple, decision-making and overall communication compe- for either practicing physicians or students. It has been operationa- tence rated by the SPs. These findings suggest that SP lized as a set of measurable communication behaviors incorporating 4,7,15 ratings of students’ communication skill cannot be patients’ preferences and values. There are three domains of used to infer students’ use of shared decision-making. behaviors common to the shared decision-making process: 1) Tools to determine students’ skill in shared decision- exchange of feelings and beliefs; 2) exchange of information about making are needed. the disease, its diagnosis and treatment; and 3) reaching clo- 4,7,15 sure. In a qualitative study examining the relationship of Electronic supplementary material The online version of this article shared decision-making to patient satisfaction, the presence or (doi:10.1007/s11606-010-1567-7) contains supplementary material, absence of shared decision-making in a given encounter did not which is available to authorized users. consistently correlate with patients’ satisfaction with their phy- Received June 11, 2010 sicians’ communication and relationship-building behavior, sug- Revised September 14, 2010 gesting that shared decision-making is only one of several facets Accepted October 25, 2010 Published online November 25, 2010 of communication that influence overall patient satisfaction. 367 368 Hauer et al.: Medical Students’ Shared Decision-Making JGIM Medical students’ competence in communication skills is conditions likely to prompt decision-making opportunities often assessed through the communication component of regarding disease management or behaviors. (Appendix 1, clinical practice examinations in which trained standardized available online) For shared decision-making to occur, one 4,23 patients typically assess students’ communication competence necessary prerequisite is a decision with multiple options . using a communication behaviors checklist. These ratings Standardized patients participated in 17 hours of training over may or may not capture medical students’ use of shared five sessions. Two different standardized patients portrayed the decision-making. For instance, communication behaviors such hypertension case and three portrayed each of the other three as building rapport, expressing empathy, and using body cases. The trainer assessed the standardized patients for language may occur in the absence (or presence) of active consistency of portrayal and checklist accuracy during training patient involvement in decision-making. Nonetheless, there is and the exam. a growing need to assess medical student engagement in shared The CPX case checklists used by the standardized patients decision-making behavior with their patients to understand how included seven communication items (listening, rapport building, trainees develop this skill. Physician belief in the benefits of professional demeanor, and addressing the patient’s perspective shared decision-making and motivation to engage in shared and needs) based on the Common Ground checklist. This decision-making are crucial facilitators of this behavior ,and it checklist was previously shown to have high reliability (rho=> is important to impart these attitudes during the formative 0.80) when completed by trained raters and high correlation with 20 24 stages of training before practice patterns are established. global ratings of communication by faculty experts (r=0.84). However, with their less mature clinical skills, students may be Standardized patients scored the communication items from 0 to more challenged than physicians by the time constraints of 1.0 on a six-point scale (0, 0.2, 0.4, 0.6, 0.8, 1.0, as defined in ambulatory encounters, which are a major barrier to shared Appendix 2, available online), with total scores reported as decision-making. We designed this study to characterize the percentages (maximum 100%). nature and amount of medical students’ shared decision- Shared decision-making coding: Four investigators (KEH, AF, making and to determine if ratings of general communication AT, GS) coded shared decision-making using a coding manual correlate with students’ use of shared decision-making. (Appendix 3, summary available online) and coding worksheet (Appendix 4, available online) from an instrument used to code physician–patient encounters. The worksheet includes checkboxes for decision moment identification and each of the METHODS key dimensions of shared decision-making within a single decision moment: exploration/articulation of perspective (beliefs, values), information sharing, and explicit closure, each of which could be done by the student, standardized patient, or Design. This was a retrospective observational study of medical both. In contrast to some other published shared decision- 6,11,17 students’ performance with standardized patients. The making scales, we captured both the student physician’s Institutional Review Board approved the study. sharing of beliefs and values and the students’ responses to information from the patient. A single worksheet was used for each decision moment, which begins when a suggestion is made Subjects and Setting. After the third-year core clerkships, all to change behavior or consider medical therapy or testing. Each University of California, San Francisco (UCSF) students are dimension was marked as present or absent for each decision required to take the Clinical Performance Examination (CPX). discussed by the student and standardized patient; each The CPX is an eight-station comprehensive standardized dimension was attributed to the student or patient only once per patient examination developed by the eight medical schools decision moment. comprising the California Consortium for the Assessment of Examples of shared decision-making decision moment Clinical Competence. Each CPX encounter lasts 15 minutes discussions between students and standardized patients are and is videotaped. After each encounter, standardized patients shown in Text box 1. There was no maximum number of decision complete a criterion-based checklist evaluating students’ moments per case; it was also possible for an encounter to have history taking, physical examination, communication and none. Each of the 240 encounters was coded by two coders, and information sharing skills. Checklist accuracy by the reconciled by consensus discussion between the two coders, or consortium’s standardized patients exceeds 95%. with other coders in the event of discrepancy, which was rare. A total of 143 UCSF medical students comprising the class of 2006 participated in the May–June 2005 CPX. The class of 2006 was 63% female. The self-described racial makeup of the class Analysis. For analysis, we defined shared decision-making as a was 48% White, 33% Asian, 3% Black, 2% Native American, 6% decision moment that included at least four of the possible ten other race, 2% unknown, and 6% multirace. We used a random decision-making elements (in addition to decision identification) number generator to select a 60-student probability sample for on the worksheet (Appendix 4, available online) in which one of the study. This sample size (n=60) gave adequate (80%) power to the four was closure of the decision by the patient. Inclusion of at detect correlations of 0.35 and outstanding power (99%) to detect least four elements ensures participation by both student and correlations of 0.5 or larger. All CPX encounters were video- patient with presence of essential domains of shared decision- recorded as part of usual exam procedure. Videotapes of the four making (exchange of feelings and beliefs, exchange of study cases from the 60 randomly selected students were information, and closure). This cutoff is similar to that used in transcribed for analysis. prior literature, with a slightly lower cutoff due to students’ earlier Communications skills cases and rating instrument: For this point in training than practicing physicians. Closure of the study, we selected four CPX cases that highlighted medical decision by the patient is essential to determine whether shared JGIM Hauer et al.: Medical Students’ Shared Decision-Making 369 Example 1: Decision Moment regarding diet modification Speaker Comment Decision moment element Student But always, you know, you're out to a Decision identification restaurant to not order just the thing that AND on the menu that looks the best. Exploration/articulation of perspective –student offers Patient Right. Student But once in a while, you know, try to Information sharing – order a salad. Try to decrease the fat. student offers That'll help your cholesterol a lot. Patient Yeah. I know that. It's just hard to do. Exploration/articulation of perspective – patient offers Student I know. Exploration/articulation of perspective – student offers Patient [It's like] you open the menu, and you Exploration/articulation of say, ‘Well, I'll get the steak today and perspective – patient offers the chicken tomorrow.’ Student Right. Keep it in mind because this is Information sharing – something that's important to your health student offers in the future. You know, cholesterol and diabetes are two of the major risk factors for heart disease. And heart disease is the number one killer. Patient Mm-hmm. Student Okay. So we need to keep these under Information sharing – control to protect you for the future. student offers Patient Okay. Got a deal. Closure – patient Student Okay. Closure – student Patient All right. Closure – patient Example 2: Decision Moment regarding diagnostic testing Patient So you don't think I need anything, like a Decision identification CAT scan or anything like that? AND Information sharing – patient elicits Student I actually don't think so. The percent Information sharing – chance of you having a tumor in there is student offers like, less than 1 percent, especially with a completely normal exam. You haven't had any symptoms until right now. And those are kind of the reasons why. Patient Okay. Student Does that, does that sound reasonable? I Exploration/articulation of don't want to pressure you into thinking perspective – student elicits one way or the other. Of course I'm open and offers to your concerns. But that's kind of just where I'm thinking right now. Patient Okay. Closure – patient Student Okay? Exploration/articulation of perspective – student elicits Patient All right. Closure – patient Text box 1. Shared Decision-Making Decision Moment Examples 370 Hauer et al.: Medical Students’ Shared Decision-Making JGIM decision-making has occurred; without closure by the patient, Association Between Communication Scores the physician may make decisions unilaterally. Traditionally, and Shared Decision Making physicians are more vocal about closure than patients (e.g., ‘we The mean (standard deviation) communication scores out of a will change your medicine’; ‘I want you to monitor your glucose’); maximum of 100 for the 60 students were: diabetes 68.71 patients’ verbalization of closure ensures their agreement. (7.86), headache 69.57 (7.99), hypertension 61.23 (6.81), and We calculated the total number of decision moments overall teen 69.19 (8.79). The correlations between number of and by decision topic. The key outcome used in correlation shared decision-making moments in a case and the respec- analyses was the number of decision moments with ≥4 tive communication score from the standardized patient elements as defined above. We used Spearman rank were low for three cases: diabetes (rho=0.07; 95% confi- correlations, a non-parametric test, to examine the association dence interval -0.109, 0.32), headache (rho = 0.10; -0.16, between number of decision moments with ≥4 elements and the 0.34), and teen (rho=0.08; -0.18, 0.33), and moderate for CPX communication score for each case. Data analyses were the hypertension case (rho=0.37; 0.13, 0.57). performed using SPSS 17.0 (SPSS, Inc., Chicago). DISCUSSION RESULTS In this analysis of student-standardized patient encounters in The 240 encounters from the 60 students generated 779 a high-stakes clinical skills examination, we found that, decision moments across all four cases. Of the 779 decision although all students engaged in some shared decision- moments, 483 (62%) had shared decision-making scores of making with their patients, the number of shared decision- four or greater, 390 (50%) included patient closure, and 312 making moments per case had limited correlation with the (40%) had both. These 312 comprised the shared decision checklist communication score rendered by standardized moment dataset. The number of decision moments per student patients. This finding implies shortcomings in existing mea- across all four cases ranged from 6.00 to 23.00; the mean sures of communication skills in that shared decision-making (standard deviation) was 13.98 (3.07). Considering each case is independent of other aspects of communication, such as individually, the number of decision moments was: diabetes students’ communication behaviors and patients’ perceptions 3.93 (2.25), headache 2.15 (1.13), hypertension 3.87 (1.23), of rapport. Shared decision-making seems to involve additional and teen 2.97 (1.22). aspects of the interaction and may challenge students working All students engaged at least once in shared decision- with standardized (or actual) patients to collaborate in care making (i.e., included at least four elements, one of which planning in ways not rewarded in typical communication was patient closure) in both the hypertension and teen cases. checklists. In contrast, for the other two cases, 5% (diabetes) and 12% CPX scores may reflect meaningful aspects of communica- (headache) of students did not engage in any shared decision- tion that differ from shared decision-making. Although shared making. decision-making is often cited as an ideal model of physician– As shown in Table 1, among the 312 shared decision patient communication, our findings of limited correlation moments, the most commonly discussed topics were medica- between shared decision-making and overall communication tions (n=98, 31%), follow-up visits (71, 23%), and diagnostic scores from standardized patients are consistent with prior testing (44, 14%). Lifestyle changes such as exercise (30, 9%) literature showing that patients’ preferences for decision- and diet (27, 10%) were discussed less frequently using shared making style are complex and variable. Approximately one third 10,15,25 decision-making. of patients may prefer a different style, particularly based Table 1. Topics of Shared Decision-Making Decision for 4 Standardized Patient Cases CASE Diabetes Headache Hypertension Teen TOTAL Decision Moment N% N % N % N% N % Adjust medications 25 8.0% 38 12.2% 35 11.2% 98 31.4% Follow-up appointment with physician 12 3.8% 5 1.6% 50 16.0% 4 1.3% 71 22.8% Get more tests 26 8.3% 7 2.2% 11 3.5% 44 14.1% Exercise 15 4.8% 15 4.8% 30 9.6% Diet change 16 5.1% 11 3.5% 27 8.7% Self-monitor glucose 14 4.5% 14 4.5% Refer to ancillary health professional 8 2.6% 1 0.3% 1 0.3% 10 3.2% Refer to another physician 6 1.9% 1 0.3% 7 2.2% Engage in safer sex 5 1.6% 5 1.6% Self-monitor blood pressure 3 1.0% 3 1.0% Talk to patient’s mother 3 1.0% 3 1.0% TOTAL 96 30.8% 70 22.4% 122 39.1% 24 7.7% 312 100.0% Sixty students each completed four cases (240 encounters), during which a total of 312 decision moments occurred JGIM Hauer et al.: Medical Students’ Shared Decision-Making 371 on their medical conditions. Other aspects of communication, In this study of medical students’ shared decision-making such as empathy and rapport, may be valued more highly than with standardized patients, we found minimal correlation decision-making style. between the frequency of shared decision-making and stan- Our results suggest that commonly used standardized dardized patients’ ratings of overall communication. All stu- patient checklists could be modified to include explicit assess- dents engaged in some shared decision-making, although they ment of shared decision-making behaviors. Our work extends focused their discussions on physician-oriented topics rather that done using the OPTION scale , another scale for assessing than patient self-management. Further study is needed to shared decision-making, in student-standardized patient determine how medical students can best engage their encounters, in which capturing balanced measures of both patients in collaborative care, and how educators can measure persons’ contributions is important in student assessment. that engagement with psychometrically sound instruments. Assessing students’ shared decision-making in standardized That knowledge would enhance both medical education and patient examinations raises practical challenges including patient care. requirements for detailed coding of interactions and extensive standardized patient training. While this task is daunting, the evidence for shared decision-making as a preferred communi- Acknowledgements: The authors thank Kathleen Kerr and Suzy 27–31 Hull for their assistance with shared decision-making coding, cation strategy is growing and the applications expanding. Joanne Batt for data management, and Steven Gregorich and To address feasibility concerns, efforts could focus on a few key Patricia S. O’Sullivan for expert advice. components of shared decision-making while still capturing both patient and physician perspectives on decision-mak- 32,33 ing. Alternatively, assessing shared decision-making in Conflict of Interest: None disclosed. formative standardized patient examinations might allow for Funding: Funding for this project was provided by Stemmler meaningful feedback from patients to students without Medical Education Research Fund of the National Board of Medical necessitating high checklist reliability. Examiners. Dr. Fernandez was also partly supported by the Arnold It is encouraging that, in our study, all students engaged in P. Gold Foundation Professorship award. some shared decision-making. Of the decision moments, almost half met our criteria for shared decision-making. This percent- Open Access: This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which per- age is comparable to findings with actual physician–patient mits any noncommercial use, distribution, and reproduction in any encounters, in which, using a slightly different threshold, half of medium, provided the original author(s) and source are credited. decision moments qualified as shared decision-making. Our results also provide insights into students’ predilection to Corresponding Author: Karen E. Hauer, MD; Department of emphasize biomedical rather than lifestyle topics while counsel- Medicine, University of California, San Francisco, 505 Parnassus Ave, M1078, Box 0120, San Francisco, CA 94143-0120, USA ing patients with a variety of clinical presentations. 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Journal of General Internal MedicinePubmed Central

Published: Nov 25, 2010

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