Shared decision-making: longitudinal changes in medical student knowledge, attitudes, and skills following an educational intervention

Abstract

Shared decision-making (SDM) promotes patient engagement and collaboration in healthcare decisions and improves patient outcomes. Despite its recognized value and inclusion in Liaison Committee on Medical Education (LCME) and Accreditation Council for Graduate Medical Education (ACGME) competencies, evidence on effective strategies for teaching SDM in undergraduate medical education remains limited. This convergent mixed-methods study evaluated medical students’ knowledge, attitudes, and application of SDM following a four-hour educational session based on the Agency for Healthcare Research and Quality (AHRQ) SHARE (Seek, Help, Assess, Reach and Evaluate) shared decision-making approach and reinforced through immediate and delayed standardized patient (SP) encounters. Students completed pre- and post-session surveys assessing knowledge, attitudes, and preferred decision-making styles. Qualitative and quantitative data from SP encounters were also analyzed using the OPTION scale and reflexive thematic analysis. The targeted class size was 60 students per year, with 17 unique SPs and 4 faculty members participating across simulation iterations from 2023 to 2024. We studied a longitudinal open cohort of medical students beginning in their first year. Because the initial knowledge survey was anonymous, we could not match students’ pretest responses to their posttest responses, making this an independent-groups comparison. For the simulation component of the study, we conducted true within-subject longitudinal analyses by following each student over time with repeated assessments. Students demonstrated high baseline SDM knowledge with minimal post-session differences, suggesting that the best use of time may be helping students apply these skills. Attitudes generally remained positive, though most students felt that SDM requires patient confidence and education for successful implementation. Immediate and delayed SP assessments showed improvements in exploring patient expectations and concerns and in explaining the benefits and drawbacks of options; however, other core interviewing and SDM behaviors showed little difference. Qualitative analysis identified three themes: the importance of rapport-building, distinctions between communication and true collaboration, and variability in students’ ability to convey knowledge in patient-centered terms. Our findings suggest pre-clinical learners have a strong conceptual understanding of SDM but need more opportunities to practice and apply these skills. Because SDM is expected to become increasingly tied to clinical reimbursement and quality metrics, identifying effective instructional methods remains essential to preparing future physicians for patient-centered care.