Shared Decision-Making Training in Family Medicine Residency: A Scoping Review

Apichai Wattanapisit; Eileen Nicolle; Savithiri Ratnapalan

doi:10.4082/kjfm.23.0273

Korean J Fam Med > Volume 45(3); 2024 > Article

Wattanapisit, Nicolle, and Ratnapalan: Shared Decision-Making Training in Family Medicine Residency: A Scoping Review

Review Article

Korean Journal of Family Medicine 2024;45(3):134-143.

Published online: May 20, 2024

DOI: https://doi.org/10.4082/kjfm.23.0273

Shared Decision-Making Training in Family Medicine Residency: A Scoping Review

Apichai Wattanapisit^1,^2,^*

, Eileen Nicolle³

, Savithiri Ratnapalan⁴

¹Department of Clinical Medicine, School of Medicine, Walailak University, Nakhon Si Thammarat, Thailand

²Family Medicine Clinic, Walailak University Hospital, Walailak University, Nakhon Si Thammarat, Thailand

³Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada

⁴Hospital for Sick Children, University of Toronto, Toronto, ON, Canada

^*Corresponding Author: Apichai Wattanapisit
Tel: +66-7547-7401, Fax: +66-7567-2807, E-mail: apichai.wa@wu.ac.th

Received December 11, 2023 Revised January 2, 2024 Accepted January 3, 2024

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Shared decisions, in which physicians and patients share their agendas and make clinical decisions together, are optimal for patient-centered care. Shared decision-making (SDM) training in family medicine residency is always provided, but the best training approach for improving clinical practice is unclear. This review aims to identify the scope of the literature on SDM training in family medicine residency to better understand the opportunities for training in this area. Four databases (Embase, MEDLINE, Scopus, and Web of Science) were searched from their inception to November 2022. The search was limited to English language and text words for the following four components: (1) family medicine, (2) residency, (3) SDM, and (4) training. Of the 522 unique articles, six studies were included for data extraction and synthesis. Four studies referenced three training programs that included SDM and disease- or condition-specific issues. These programs showed positive effects on family medicine residents’ knowledge, skills, and willingness to engage in SDM. Two studies outlined the requirements for SDM training in postgraduate medical education at the national level, and detailed the educational needs of family medicine residents. Purposeful SDM training during family medicine residency improves residents’ knowledge, skills, and willingness to engage in SDM. Future studies should explore the effects of SDM training on clinical practice and patient care.

Keywords: Family Medicine; Medical Education; Residency; Shared Decision-Making; Training

INTRODUCTION

In primary care settings, clinical decisions are a part of daily practice. Although it is recognized that shared decision-making (SDM) between physicians and patients is optimal, this is not regularly implemented in clinical practice [1]. Lack of SDM can have several negative consequences including affecting the physician-patient relationship, negatively impacting physician and patient satisfaction, and increasing risk of medico-legal issues [2,3]. The spectrum of clinical decision-making spans a paternalistic model at one end—which has been the traditional approach in medicine historically—and an informed, patient-centered choice model at the other end [2,4-7]. The paternalistic model illustrates an unequal power structure between physicians and patients where physicians tend to make decisions based on the what they consider as a patients’ best interest [3]. Inversely, the informed choice model is a shift of power from physicians to patients based on a patient’s autonomy and other ethical principles such as beneficence and nonmaleficence [8]. An SDM model is a middle ground, that takes into account physician and patient perspectives [2].

Therefore, SDM represents a more equal distribution of power between physicians and patients [3]. SDM supports clinical decision-making through discussion, negotiation, and agreement based on physician expertise (e.g., clinical knowledge and skills, resources, patient’s conditions) and patient factors (e.g., values, beliefs, knowledge, psychosocial background) [3]. Accordingly, SDM is defined as “an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences.” [9] Participants who are exposed to SDM express higher trust in their physicians and are less likely to resort to formal complaints or legal action [10]. Furthermore, a systematic review concluded that SDM was an effective and useful method to employ to reach a treatment agreement for making long-term decisions [11].

Thus, SDM is a practical and applicable approach for primary care and family medicine practice [2,3,12,13]. However, a lack of familiarity with SDM is a barrier to implementing it in clinical practice [14]. Structured and standardized training activities have been shown to improve the implementation of SDM in clinical practice [15-17]. However, the literature on training or educational programs for SDM in family medicine residency and their impact is limited. This study aimed to explore the impact of SDM training in family medicine residency.

METHODS

This scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-extension for scoping reviews [18].

1. Search Methods and Databases

A systematic search was performed using the following four databases: Embase (via Ovid), MEDLINE (via PubMed interface), Scopus, and Web of Science. The search retrieved articles published from the inception of each database to November 9, 2022. The search terms were related to SDM training in family medicine residencies and included the following four components: (1) family medicine, (2) residency, (3) SDM, and (4) training. Terms within each component were combined using the Boolean “OR,” and the Boolean “AND.” The search terms were applied to each database, and the syntax was modified for each database, if appropriate (Appendix 1).

2. Study Selection and Eligible Criteria

The study selection method followed the PRISMA flow version 2020 [19]. The inclusion criteria were as follows: (1) articles related to SDM training in family medicine residency, (2) articles representing a primary study, and (3) articles published in English. Articles were excluded if they met one of the following criteria: (1) non-empirical studies (e.g., systematic review, scoping review, narrative review), (2) non-research articles (e.g., review article, study protocol, perspective, opinion, commentary, editorial, letter to the editor, book chapter), (3) conference abstracts, or (4) articles not published in English.

3. Data Extraction and Synthesis

General information was extracted from each article, including the first author’s name, year of publication, and country of study. Each study was extracted to describe its design, participants and settings, educational programs/trainings/components, and outcomes. Study characteristics, educational components, and SDM outcomes were qualitatively synthesized.

RESULTS

Of the 813 articles found in the four databases, duplicate removal yielded 522 articles and abstract review yielded 14 articles. After full-text review, six articles were selected for synthesis (Figure 1).

1. Characteristics of the Included Studies

Of the six studies, four studies [20-23] were conducted in Canada and two studies [1,24] in the Netherlands. All studies were published after 2000, and half of them were published between 2021 and 2022 [1,22,24]. A variety of study designs were employed: pre- and post-interventional studies [20,22] randomized controlled trials [23], mixed-methods studies [21], Delphi studies [1], and qualitative studies [24]. Table 1 summarizes the details of the included studies.

One study was conducted to obtain expert opinions and did not include family medicine residents as study participants [1]. Five studies included family medicine residents as a target population [20-24]. Three studies included only family medicine residents [20,22,24], whereas two studies had mixed participants, that is, family medicine residents and other health practitioners such as family physicians and nurses [21,23].

2. Shared Decision-Making Training in Family Medicine Residency

Three training programs (decision boxes [Dboxes], DECISION+2, SDM-family medicine [SDM-FM]) were implemented in family medicine residency training in Canada [20-23]. All training programs incorporated the concepts of SDM and disease- or condition-specific issues. Two studies conducted by Baghus et al. [1,24] highlighted the requirements of SDM training in postgraduate medical specialty training and family medicine residency.

One of the studies used Dboxes which consist of eight training tools for clinician-patient communication and SDM for eight clinical situations (i.e., reduction in symptoms of Alzheimer’s disease, prevention of cardiovascular disease [aspirin], screening for colorectal cancer, screening for fetal trisomy 21, prevention of cardiovascular disease [statins], evaluating risks of breast and ovarian cancers, prevention of osteoporotic fractures, and screening for prostate cancer) [21]. Family medicine residents had positive perspectives towards several aspects of the Dboxes as effective training tools for SDM and useful tools for communicating with patients using SDM concepts [21]. However, some barriers, such as clarity and complexity of the tools, were highlighted [21].

The DECISION+2 study focused on SDM for acute respiratory tract infections [20,23]. The format of DECISION+2 was changed across the three cohorts of family medicine residents that participated in the study. Initially for the 1st cohort, the program comprised a five-module online self-tutorial and an interactive workshop [20,23]. Subsequently, for the second cohort, the interactive workshop was removed, as the workload of the program was considered too heavy, and only a five-module tutorial was used [20]. Finally, for the third cohort, an additional module was inserted as a six-module online tutorial [20].

Dion et al. [20] in 2016 investigated the effects of SDM training on acute respiratory tract infections among three cohorts of family medicine residents. The scores for overall knowledge and knowledge of each domain (diagnosis, treatment, and SDM) significantly improved (P<0.001) [20]. However, a small effect of the training on SDM knowledge was reported compared to other domains (diagnosis and treatment) [20].

Légaré et al. [23] in 2012 conducted a cluster randomized trial focusing on the DECISION+2 initiative and showed that patients who consulted physicians in the intervention group, had a significantly lower rate of antibiotic use compared to the control group (27.2% versus 52.2%). A subgroup analysis among residents showed positive outcomes such as a reduction in antibiotic use among patients between the intervention group (28.6%) and the control group (46.7%) [23]. The training improved patients’ active roles in the decision-making process (intervention group: 67% versus control group: 49%, P<0.001) [23].

The SDM-FM consisted of a 1-hour online lecture and a 1-hour online workshop [22]. The lecture included the Canadian Task Force on Preventive Health Care recommendations and SDM key issues [22]. The workshop emphasized the use of patient decision aids and optimal communication practices [22]. Grad et al. [22] evaluated the willingness to engage in SDM among family medicine residents before and 6 months after the SDM-FM program. Overall scores increased from 6.96 (out of 10) to 7.39 (P=0.007) post program [22]. There was a statistically significant improvement in residents’ confidence in using SDM in clinical practice from 6.43 to 7.61 (P<0.001) [22].

Baghus et al. [1,24] conducted two studies related to family medicine residency in the Netherlands. One study sought consensus around entrustable professional activities (EPAs) and behavioral indicators for SDM for all postgraduate medical specialty programs at the national level [1]. Four EPAs and 18 behavioral indicators were established [1]. The other study focused on the needs of SDM learning in family medicine residents which was identified as an area of priority for the residency curriculum [24]. Some areas of need that were identified in terms of building resident capacity for participating in SDM included knowledge of SDM processes, communication skills, as well as diagnostic and treatment options [24]. This study suggested that teaching SDM should happen in a longitudinal and integrated fashion [24]. A variety of teaching and learning activities were considered to support improvement in SDM skills. These included workplace-based practices, video-recorded consultations, role-playing opportunities, learning from concrete examples and guidelines, and reflection and feedback [24].

Figure 2 illustrates the SDM training program for medical condition-specific topics based on diagnostics, preventive health, and treatment options. Figure 3 summarizes SDM training formats, expected competencies, evaluation methods, and suggested assessments.

DISCUSSION

Six studies related to SDM training in family medicine residency from four databases were included in this scoping review. All of the studies were contemporary, reflecting that this is an upcoming area of research. Four studies focused on three SDM training programs and demonstrated positive effects on family medicine residents’ knowledge, skills, and willingness to engage in SDM. This lends credibility to further exploring how SDM can be incorporated into training programs.

SDM was introduced to academic fields in the late 1980s and early 1990s [25]. However, all the studies included in this scoping review were published after the 2020s. This reflects slow progress in SDM training in family medicine residency. A possible reason for this could be that SDM may not be emphasized as a core component of physician-patient interactions compared to the concept of patient-centered care. Therefore, there is a need to highlight SDM concepts formally in postgraduate family medicine education. In addition, two studies on DECISION+2 revealed that dynamic changes are needed, with learning activities adjusted based on feedback from residents to best address their needs, which can be time-consuming to implement [20,23].

Interestingly, all programs included online elements, such as online lectures, workshops, and modules. This reflects the changing educational landscape in which online learning is an integral part of disseminating information. Web-based training programs for SDM have been implemented in different settings for clinicians [26-28]. Electronic learning (e-learning) and online learning have been used in undergraduate and postgraduate medical education for more than a decade [29-34]. The coronavirus disease 2019 pandemic was a catalyst for a new online era in medical education [35]. Although online learning opportunities can be effectively used to deliver SDM training in family medicine residency training, the development and implementation of learning materials are considered challenges in online medical education [36]. Furthermore, any online training program should be designed based on users’ needs and context [37].

A systematic review by Singh Ospina et al. [38] revealed a variety of educational programs for SDM for various groups of learners. Programs ranged from a few hours to several months and consisted of online and in-person activities [38]. However, the effectiveness of educational programs for SDM remain inconclusive [38]. This highlights that educational initiatives around SDM require further exploration and study.

Two studies focused on different educational aspects of SDM. One study examined expert opinions on developing EPAs, which are known to be effective educational tools [1]. The study also looked at behavioral indicators for SDM at the national level for all postgraduate medical specialty programs [1]. Another study explored the needs of family medicine residents for SDM training, including knowledge and skills, practice, reflection and feedback, longitudinal and integrated training, and awareness [24].

Each educational program included in this scoping review consisted of two main components: medical conditions related to SDM and SDM concepts [20-23]. Although the educational programs were effective in improving overall SDM competencies, several SDM domains related to knowledge, skills, and attitudes should be emphasized in the training. Diouf et al. [39] reviewed potential training strategies for SDM that presented a wide range of effectiveness, from 0 (self-appraisal learning) to 60% (peer-to-peer group learning). A Cochrane review analyzed interventions to increase the use of SDM by healthcare professionals [40]. Educational interventions (e.g., educational meetings, educational materials, and educational outreach visits) had uncertain effects on the use of SDM [40].

All the included studies were conducted in only two high-income countries (Canada and the Netherlands). This is an important consideration when applying the findings of the present study. Each country has a different context in terms of family medicine residency training, clinical situations, patient characteristics, health systems, and cultural backgrounds. SDM cannot be separated from these factors. Therefore, SDM training in family medicine residency should be adjusted and designed based on context-specific considerations.

The results of this scoping review and previous systematic reviews support further research on SDM programs. Studies on SDM training in family medicine residency are scarce. Future educational programs should focus on the needs of family medicine residents in the context of training and clinical practice. Evidence-based theories and methods should be considered when developing and implementing new educational programs for SDM that are dynamic and responsive to residents’ needs. Knowledge of common medical conditions related to SDM should be introduced to family medicine residents. Training in SDM concepts may need to focus on higher levels (i.e., level 3: behavior and level 4: results) of training outcomes, according to the Kirkpatrick model [41].

This scoping review had several strengths. To increase the yield of search results, the review included studies that focused on family medicine residents and other participants. Studies with any design were included to fully appreciate the breadth of the literature. This study has two major limitations. First, all the included studies were conducted in Canada and the Netherlands. This may limit the generalizability of the results. Second, various outcome measurements were identified in the small number of included studies. Therefore, the results of this scoping review may not represent clear patterns and common methods used for SDM training in family medicine residency.

CONCLUSION

This scoping review highlights the characteristics of SDM training among family medicine residents. Based on a few studies, existing SDM training programs reflect positive outcomes in improving residents’ knowledge, skills, and willingness to engage in SDM in clinical practice. Standardized tools, such as EPAs and behavioral indicators for SDM in family medicine residency are needed to better quantify educational outcomes. The design and implementation of SDM training programs should be based on the needs and contexts of family medicine residents. Future studies should explore the effects of SDM training on clinical practice and patient care.

Notes

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

Figure. 1.

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram. SDM, shared decision-making.

Figure. 2.

Shared decision-making training program for medical condition-specific topic.

Figure. 3.

Shared decision-making training formats, expected competencies, evaluating methods, and suggested assessments. SDM, shared decision-making; EPA, entrustable professional activity.

Table 1.

Summary of the included studies

Author (year, country)	Study design	Participant and setting	Educational program/training/component	Outcome
Giguere et al. [21] (2014, Canada)	Sequential mixed methods study (quantitative phase and qualitative phase)	Quantitative phase: 101 clinicians, including family physicians, nurses, and residents (54% of all clinicians) from six primary healthcare clinics (four teaching and two non-teaching clinics) in four cities	Eight Dboxes (clinical training tools for clinician-patient communication and SDM) included eight health topics were sent via emails weekly (one Dbox per week): Dbox 1: “cholinesterase inhibitors to reduce the symptoms of Alzheimer’s disease (ChEIs)”; Dbox 2: “acetylsalicylic acid for primary prevention of cardiovascular disease (ASA)”; Dbox 3: “fecal occult blood test to screen for colorectal cancer (FOBT)”; Dbox 4: “serum integrated test to screen women for fetal trisomy 21 (Prenatal)”; Dbox 5: “statins for primary prevention of cardiovascular disease (Statins)”; Dbox 6: “BRCA1/2 gene mutation test to evaluate the risks of breast and ovarian cancer (BRCA)”; Dbox 7: “bisphosphonates to prevent osteoporotic fractures in postmenopausal women (Osteo)”; Dbox 8: “prostate-specific antigen test to screen men for prostate cancer (PSA)”	Quantitative phase: 54% rated “practice will be changed and improved” (76% for “counseling approach”, 51% for “disease prevention or health education”); 52% rated “learned something new”; 96% rated “the information is totally or partially relevant for at least one of their patients”; 65% rated “information use to discuss with patient or with other health professionals”; 89% rated “expect patient health benefits as a result of applying this information”; 72% rated “allows the patient to make a decision that is more in line with his/her personal circumstances, values, and preferences”
	Quantitative phase: webbased questionnaires to rate the interest for each Dbox topic
	Qualitative phase: a 60-minute semistructured focus group for family physicians, nurses, and residents and a 30-minute interview for the medical director in each clinic	Qualitative phase: eight family physicians, nurses, and residents who extremely responded to the web questionnaires (high and low scores) and the medical director of each clinic from four primary healthcare clinics		The average score of intention to use Dboxes in practice was 5.6 (on a scale 1 [strongly disagree] to 7 [strongly agree]).
				Qualitative phase: Theme 1: “learning with the Dbox”: Dboxes could support resident’s training; Theme 2: “counseling patients with the Dbox”: Dboxes could support information and options to communicate with patients; Theme 3: “critical barriers to implementation: optimizing the intervention”: 3.1 “adding a patient decision aid”; 3.2 “improving clarity of the information for some Dboxes”; Theme 4: “external factors influencing Dbox use”: 4.1 “patient preferences”; 4.2 “accessing the Dboxes”; 4.3 “time”; 4.4 “opinion leader”; 4.5 “journal club”; 4.6 “clinical context”; 4.7 “organizational context (setting)”; 4.8 “interprofessional approach”; 4.9 “government incentive”
Légaré et al. [23] (2012, Canada)	Cluster randomized trial (intervention: DECISION+2 shared decision-making training program vs. control: usual care)	Patients (children and adults) who consulted; family physicians (physician teachers or residents) from 12 walk-in clinics (family practice teaching units) affiliated with a family medicine residency training institution	The DECISION+2 SDM training consisted of an online selftutorial and an interactive workshop	Primary outcome: percentage of patients who decided to use antibiotics immediately after consultation; at baseline to after intervention: (1) overall: intervention group: 41.2% to 27.2%; control group: 39.2% to 52.2%; absolute difference=25.0%; adjusted RR, 0.5; 95% CI, 0.3 to 0.7; (2) family medicine residents: intervention group: 37.5% to 28.6%; control group: 44.4% to 46.7%; absolute difference=18.1%; adjusted RR, 0.6; 95% CI, 0.4 to 0.9
		At baseline: Intervention group (five clinics): 182 patients and 151 physicians; control group (four clinics): 171 patients and 99 physicians	Two-hour online self-tutorial (five modules): module 1: “introduction” (SDM and ARIs); module 2: “diagnostic probabilities”; module 3: “treatment”; module 4: “effective communication of risk and benefits”; module 5: “promoting active patient participation”	Secondary outcomes: percentage of patients who reported active roles in the decision-making process after intervention: intervention group vs. control group: 67% vs. 49% (P<0.001) (statistical significance in both teaching physicians [P<0.001] and residents [P=0.03])
		After intervention (2 weeks after the initial consultation): Intervention group (five clinics): 181 patients and 162 physicians; control group (four clinics): 178 patients and 108 physicians	Two-hour interactive workshop: (1) diagnostic probabilities of ARIs; (2) treatment options; (3) effective communication strategies; (4) patients’ values and preferences; (5) decision support tools	Other secondary outcomes among patients (i.e., decisional conflict, quality of decision, quality of life, intention to engage in SDM, adherence to decision, repeat consultation for the same reason, regret over decision) and physicians (i.e., decisional conflict, quality of decision, quality of life, intention to engage in SDM, intention to follow clinical guidelines) were not significantly different between the intervention and control groups
Dion et al. [20] (2016, Canada)	Pre- and post-interventional (a webbased tutorial) study	247 second-year family medicine residents (63.8% of second-year residents) from a residency program (three cohorts: 2012–2013, 2013–2014, and 2014–2015) logged in to the web-based tutorial	A 2 to 3-hour-web-based tutorial entitled “SDM to treat ARI” (DECISION+2); the SDM training program had been changed over the 3 years of study period: 2012–2013: a 5-module web-based tutorial, a 2-hour interactive workshop, and a decision aid; 2013–2014: a 5-module web-based tutorial and a decision aid; 2014–2015: a 6-module web-based tutorial and a decision aid	A total of 109 residents logged in to the web-based tutorial and completed both pre- and post-tests (41 did not complete any tests, 95 completed the pre-test only, and 2 completed the post-test only); median number of connections, 2 times (IQR, 1–4); median total time use, 2.22 hours (IQR, 0.38–3.32)
				The median knowledge post-test scores were significantly improved in all categories (P<0.001): overall (10 pints): 4 (IQR, 3–5) vs. 7 (IQR, 6–8); diagnosis (4 points): 2 (IQR, 1–2) vs. 3 (IQR, 2–4); treatment (3 points): 2 (IQR, 1–2) vs. 3 (IQR, 2–3); and SDM (3 points): 1 (IQR, 0–1) vs. 1 (IQR, 1–1)
			The final 6-module-web-based tutorial consisted of module 1: “introduction” (SDM and ARIs); module 2: “diagnostic probabilities”; module 3: “treatment”; module 4: “effective communication of risk and benefits”; module 5: “promoting active patient participation”; module 6: integrate all acquired knowledge (added in 2014)	The comparisons of the number of residents who answered each question correctly between the pre- and post-test showed significant improvement for 3/4 questions regarding diagnosis, 2/3 questions regarding treatment, and 1/3 questions regarding SDM
Grad et al. [22] (2022, Canada)	Pre- and post-interventional stud	First and second year family medicine residents from a residency program: 73/200 residents attended the online lecture and workshop; 64/73 residents completed the pre-test; 44/64 residents completed the post-test	The educational intervention (called SDM-FM) consisted of a 1-hour online lecture followed by a 1-hour online workshop using small group methods: the lecture: (1) recommendations from the Canadian Task Force on Preventive Health Care; (2) concept of recommendation strength; (3) key components of SDM (i.e., risk communication, value clarification); the workshop: (1) use of patient decision aids; (2) communication skill practice by a role play of a physician-patient encounter	Among 44 residents who completed both pre- and post-tests: overall mean score (out of 10): 6.96 vs. 7.39 (P=0.007); item 1: “Is SDM a necessary aspect of clinical practice?” 9.16 vs. 9.43 (P=0.141); item 2: “Is SDM welcomed by patients?” 7.68 vs. 7.95 (P=0.199); item 3: “Is SDM a good use of clinician’s time?” 8.00 vs. 8.36 (P=0.185); item 4: “Are clinicians confident using SDM in clinical practice?” 6.43 vs. 7.61 (P<0.001); item 5: “Is SDM important in situations where there are strong clinical recommendations?” 6.91 vs. 7.45 (P=0.160); item 6: “In a low stakes situation, do clinicians feel comfortable providing care that is not aligned with their clinical recommendation?” 7.00 vs. 7.41 (P=0.202); item 7: “In a high stakes situation, do clinicians feel comfortable providing care that is not aligned with their clinical recommendation?” 3.57 vs. 3.52 (P=0.924)
Grad et al. [22] (2022, Canada)	Willingness to engage in SDM was assessed using the seven-item incorpoRATE measure before and 6 months after the educational intervention
Baghus et al. [1] (2021, the Netherlands)	Three-round modified Delphi study	32 Experts in various roles (i.e., lecturers, researchers, clinical specialists, behavioral scientists, policy officers, patient representatives) and various medical fields (i.e., family medicine, orthopedics, pediatrics, medical oncology, radiation oncology, physiotherapy)	Consensus on EPAs and behavioral indicators for SDM to support self-directed learning during postgraduate medical specialty programs (including family medicine)	Of 32 experts, 30 experts (93.75%) agreed with the consensus consisted of four EPAs and 18 behavioral indicators for SDM: EPA 1: “The resident discusses the desirability of shared decision making with the patient” (four behavioral indicators under this EPA); EPA 2: “The resident discusses the options for management with the patient” (six behavioral indicators under this EPA); EPA 3: “The resident explores the patient’s preferences and deliberations” (four behavioral indicators under this EPA); EPA 4: “The resident takes a well-argued decision together with the patient” (four behavioral indicators under this EPA)
Baghus et al. [24] (2022, the Netherlands)	Qualitative study using video-stimulated interviews	17 First (n=10) and third year (n=7) general practice residents from training institutes in four cities	Resident’s educational needs for learning SDM emerged from interviews	Five themes were identified: Theme 1: “Acquiring knowledge and skills needed to perform SDM”: residents required knowledge of SDM process, knowledge of diagnostic and treatment options, communication skills for SDM, and skills for SDM in challenging situations; Theme 2: “Practicing SDM”: residents required workplace-based practice, concrete examples to apply SDM, learning from video-recorded consultations of peers and SDM experts, roleplays with peers or simulated patients, and guidelines; Theme 3: “Reflection and feedback”: residents required reflection and feedback from various sources (e.g., themselves, peers, supervisors) and methods (e.g., video-recorded consultations, checklists); Theme 4: “Longitudinal and integrated training”: residents required early SDM training in their residency program, longitudinal training in SDM, and integrating training with other topics (e.g., evidence-based medicine training); Theme 5: “Awareness and motivation for performing SDM”: residents required awareness of the importance of SDM and priority of SDM in the residency curriculum
Baghus et al. [24] (2022, the Netherlands)	Qualitative study using video-stimulated interviews	17 Videos recording resident-patient encounters were watched by the researcher and the resident during the interviews

Dbox, decision box; SDM, shared decision-making; ARI, acute respiratory tract infection; RR, relative risk; CI, confidence interval; IQR, interquartile range (1st quartile, 3rd quartile); EPA, entrustable professional activity.

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Appendices

Appendix 1.

Search terms

Component	Search terms
Family medicine	“family medicine” OR “family practice” OR “general practice” OR “general practitioner” OR GP OR “primary care”
Residency	resident OR residency OR registrar OR trainee OR student
Shared decision-making	“shared decision-making” OR “shared decision making” OR (“decision making” AND shared)
Training	train OR education OR educate OR studies OR study OR learn OR practice OR workshop
Final search terms	(((“family medicine” OR “family practice” OR “general practice” OR “general practitioner” OR GP OR “primary care”) AND (resident OR residency OR registrar OR trainee OR student)) AND (“shared decision-making” OR “shared decision making” OR (“decision making” AND shared))) AND (train OR education OR educate OR studies OR study OR learn OR practice OR workshop)