Vital Signs

Learning to share the decision-making process

By Amos Esty

Photo by Jon Gilbert Fox

Cathleen Morrow (left) and Virginia Reed led the development of a curriculum on shared decision-making for medical students.

Since 2009, every student at Geisel School of Medicine has received a hands-on introduction to shared decision-making as part of the third-year family medicine clerkship. Today, this curriculum remains the only one of its kind at a U.S. medical school.

Clinical trials have shown the effectiveness of shared decision-making in improving outcomes and patient satisfaction, and a recent essay in the New England Journal of Medicine referred to shared decision-making as "the pinnacle of patient-centered care." But despite the growing recognition of its importance, shared decision-making has not been widely incorporated into medical education.

That changed at Geisel in 2009, when a grant from the Health Resources and Services Administration facilitated the development of a shared decision-making curriculum.

Cathleen Morrow, M.D., the director of the family medicine clerkship, was part of the team that created the curriculum, and she leads the teaching of the material. She believes there are tangible benefits to training medical students to understand and practice shared decision-making. "If patients are engaged in decision-making and they make quality decisions that are based on their own preferences and values, they have better outcomes, they are less likely to have regret, and they are more likely to follow through on treatments," she says.

Virginia Reed, Ph.D., the director of the Center for Program Design and Evaluation, also helped develop the curriculum and continues to work on evaluating its effectiveness—and she shares Morrow's belief in its importance. "There are lots of situations in everyday primary care where there are preference-sensitive decisions and where the patients' values and wishes ought to come into the selection of the option," she says.

On the first day of the clerkship, the students are asked to help simulated patients make a decision about their care. The encounters are recorded, and the students watch themselves on video and discuss selected clips with faculty and other students. After the encounter, the students receive an introduction to shared decision-making, including discussions of its history and how it helps patients take an active role in the decision-making process.

Then the students scatter across the country for six weeks to work with family physicians. Online discussion groups help them continue to consider how to incorporate shared decision-making into patient care. When they return to the Geisel campus, they have another encounter with a simulated patient, this time to discuss a more complex medical decision.

As Morrow and Reed noted in a recent paper in the journal Family Medicine, the curriculum appears to improve the students' ability to use shared decision-making to help patients make a difficult decision. It also helps them understand what it means to practice shared decision-making.

"The way they talk about shared decision-making changes," Reed says. "In the most basic sense, they get it. They understand what it means."

Morrow says that when she started this project she was doubtful that third-years would be ready to learn about shared decision-making. "I was really concerned that they needed more content about primary care," she says. "And one of the many things I've learned is that I didn't have any reason to be so doubtful. It turns out they are very ready and, in fact, I now believe that teaching these shared decision-making skills in parallel with the core curriculum in family medicine and in primary care is very appropriate, and it enriches students' understanding and uptake."

Teaching the curriculum has even changed Morrow's own practice as a physician. "I had to go through this process myself," she says. "I started to hear myself in the office talking to patients in a way I had not talked before I started developing this curriculum."

Since the publication of the article in Family Medicine last fall, Morrow and Reed have received inquiries from other medical schools interested in developing similar programs. They are working now on helping to make the curriculum transferrable to other schools.

"I have come to appreciate the power of early training in this complex skill," Morrow says. "Teaching shared decision-making to medical students reinforces the importance of the communication, relationships, and patient-centeredness that are at the heart of all excellent primary care."