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

Background: Shared decision making is critical to patient-centered care and yet there is limited consensus on effective teaching approaches for training physicians in this domain. As a collaborative process in which the patient and physician co-create a decision, patient and relational agency may be important contributors and studies with patient-reported outcomes may identify successful approaches and determine gaps in pedagogy.  The authors conducted a systematic review of educational interventions for shared decision making, focusing on patient-reported outcomes and consideration of agency.   Methods:   Ovid MEDLINE, Embase, and Web of Science were searched for studies describing educational interventions with patient-level outcomes published between January 2000 and January 2020. Articles were excluded if they were not in English, included only patient interventions, or reported only physician outcomes.  Quality assessment was performed using the Medical Education Research Study Quality Instrument (MERSQI).  Data about the educational methods used were extracted and included studies were assessed for quality. Thematic analysis was performed to identify the potential role of agency.  Results:  26 articles were identified describing 17 unique studies.  Educational interventions were diverse in duration and content, with multiple components.  Three-quarters of studies used role play or simulated patients and 82% included tools to facilitate shared decisions.  Although no articles explicitly discussed facilitating agency as a component of the intervention or as an outcome, one qualitative study demonstrated themes of patient and relational agency.  Conclusions:  Educational interventions included small group discussion, decision aids, role play, and simulated patients, and improved a range of patient outcomes, but our study included only studies including practicing physicians, limiting applicability to trainees and other health care providers. Interventions have not included explicit instructional design around agency, but qualitative analyses demonstrated interventions may facilitate agency and shared decision making. Future instructional strategies should consider the complexity inherent in co-constructing decisions.