1. Shared Decision Making in a Family Medicine Clerkship—Five Years of Teaching and Outcomes Vince WinklerPrins MD, Pete Ziemkowski MD, Ken Yokosawa MD, Stephen DeLapp MD, Cathy Abbott MD, Suzanne Clarke MD, Sreeram Gonnalagadda MD

2. Goals  Review need for shared decision making (SDM) curricula in medical education  Review our efforts to integrate SDM deeply into our teaching  Outcomes of our work 2

3. 3 Agenda  Background and Rationale  Curricular development  Current SDM curriculum  Assessments  Community clerkship director experiences  Questions

4. Background Michigan State University College of Human Medicine –Founded on service to the people of the state –Campus based educational system 4

5. Rationale  Key aspect of professional work: assisting patients in making decisions about their health  Calls by leading health reformers for SDM –Institute of Medicine (2000)—”A patient-provider partnership” –Institute for Health Care Improvement (Berwick) –Wennberg—STFM 2009 annual spring conf.  SDM operationalizes concepts of patient centeredness and the PCMH  Complex communication skill not otherwise taught in medical school—where? 5

6. Curricular development  2000 HRSA grant on SDM for CA screening and smoking cessation—funded 2002  Development of RIPUU model –R—Role of patient in decision making –I—Issues involved in screening (pros/cons/alternatives) –P—Patient preference –U—Uncertainties –U—Assess patient for Understanding 6

7. Curricular development  Initial elements and assessments 1.One hour introductory lecture/video 2.Online case based prostate and colon CA screening SDM exercise with feedback  Current elements and assessments 1.Two hour SDM lecture/discussion including online interactive module 2.Online prostate cancer SDM exercise with feedback 3.Two hour smoking cessation lecture/discussion/practice 4.Required reading of “Informed Decision Making in Outpatient Practice” 5.Patient safety—prescription writing with SDM—element added 2009 6.30 minute student presentation on screening topic involving SDM elements 7.Required smoking cessation and screening/prevention activities by student 8.Performance based assessment on cancer screening and smoking cessation 7

8. Current SDM curriculum 8 2 hr lecture with on-line tutorial

9. Current SDM curriculum 9 on-line prostate CA screening SDM with feedback

10. Current SDM curriculum 3. Two hour smoking cessation lecture/discuss/practice—5 A’s 4. Required reading of “Informed Decision Making in Outpatient Practice” 5. Patient safety—prescription writing with SDM 6. 30 minute student presentation on screening topic involving SDM elements 7. Required smoking cessation and screening/prevention activities by student 8. Performance based assessment on cancer screening and smoking cessation—separate assessments evolved into combined assessment 10

11. Current SDM curriculum 11 Performance based assessment

12. Assessments  2004—student focus groups –Liked the tools –Integration is challenging—“its all complicated”  6+ years of performance based assessment results--~5% of students do not integrate concepts well (failures) 12

13. Assessments 2009 online student survey –Audience: 150+ 3 rd and 4 th year students who had completed clerkship –57% response rate (single request) –Question: Value of SDM. 1-5 Likert (not valuable to extremely valuable) Average: 3.89, 80% very or extremely valuable –Question: Amount of curricular focus on SDM  54% “just right” 13

14. Assessments  2009 online student survey comments –In what way have you used or not used these concepts?  “I was working with a resident who hadn’t quite mastered the subtleties of the English language. After she explained the treatment options the patient asked me to clarify some of the details of the decision she was to make. I had to use the concepts of shared decision making in order to not give my biased opinion as to what the patient should choose.”  “When helping patients develop birth plans.”  “Discussing (along with my attending) treatment options for a patient with GI cancer.”  “These skills are needed in all areas of medicine and I have used them in all clerkships.”  “I haven't really had much of a chance to use the shared decision making as a student because of the fact that students don't often have the opportunity to discuss treatment decisions with patients, as the focus for us is generally placed more on gathering a history, while the resident or attending then makes the treatment decisions and discusses them with the patients.” 14

15. Assessments  Comments continued:  “I am married and so shared decision making is an integral part of keeping two people who both have their own perspectives happy.”  “I don't know that I've ever consciously used it, but it's so ingrained in me from my own beliefs and the focus of our curriculum that it comes naturally.”  “In internal medicine most of what I saw was straight "this is what we are going to do." And the patient either said "okay" or didn't say anything at all. But in defense of internal medicine, that was mostly inpatient, and I think shared decision making is a lot more practical to practice in an outpatient setting. Somebody coming to the hospital with heart failure and an ejection fraction of 15% is going to be lobbied to get a pacemaker. The pros and cons are discussed, but the clear preference of the physician for doing the intervention is clear.”  “I believe this is a common skill that should be screened for during the interview process for Medical School.” 15

16. Community clerkship director experiences 16

17. Acknowledgements Initial Development –Carol Keefe PhD –Mary Noel PhD –William Wadland, MD –Margaret Thompson, MD 17

18. Questions? 18

19. 19 Thank You!