Exploring training in shared decision-making in the medical school curriculum: Mapping the perspectives and experiences of students and providers

Where is shared decision-making in the medical school curriculum? What was the problem?

During a Doctors as Teachers Special Study Unit (SSU) a medical student asked for help preparing for their clinical skills assessment in respect of shared decision-making (SDM). Despite having research expertise on SDM, as an SSU provider I was not aware of the content of the medical school curriculum in respect of SDM. I spoke with clinical skills tutors and learned that training in SDM is minimal during the early years of the curriculum and when it does feature, it is not necessarily a core aspect of teaching. However, SDM is integral to patient-centred care. NHS England’s personalised care plan (1) includes training more clinicians in SDM. Therefore, SDM should be a core theme across all aspects of the undergraduate curriculum.

What did we do?

Our aim was to explore student and provider perspectives of SDM training with a view to improving delivery on the undergraduate medical school curriculum. We used an ‘Empathy Map’ (2) to gauge the experiences and needs of students, and a ‘Systems Map’ (3), co-produced with tutors and providers, to help visualise the patterns and relationships of SDM within the curriculum.

To optimise student engagement, we coordinated workshops within existing learning sessions, across two different aspects of the curriculum (clinical placement and SSU setting). This was with a view to encouraging students to think in the role of clinicians vs. educators when discussing their experiences. Empathy Maps are designed with a large ‘empty head’ in the middle of the paper, divided into sections with the titles: See, Say, Do, Hear, Think and Feel, Successes and Challenges. Online software was used to host the empathy map for the first workshop, due to a hybrid delivery (face-to-face/online). A paper-based map was used with the second group.

The tool enabled the group to empathise with the needs of an imagined student without feeling the need to contribute information explicitly about them as an individual. The completed empathy maps, and a proposed summary of outcomes, were circulated to the students by email following the workshop, to gather any further reflections and to reach a consensus on the successes and challenges that the activity had highlighted.

We then hosted a second workshop with the objectives identifying gaps in the curriculum in relation to SDM teaching when compared with GMC-recommended themes, and making suggestions for innovation and change. The group for this workshop were informed of initial findings from the first student workshop, and we planned to achieve these objectives via a group task using a systems map. A systems map is a visualisation tool used to understand component parts of a complex system and their interactions. An ‘onion’ shaped template (with the five years of the curriculum represented by concentric layers) guided initial group discussions. However, when it became apparent that the template was not required to aid facilitation of discussion amongst teachers/providers, we opened up to free-flow conversation and note-taking. Following this second workshop, a draft report and proposed outcomes were circulated to the group for feedback before finalising.

What did we learn?

Key findings from the students included:

• A request for more help with translating evidence-based medicine into communication skills and practice.
• Recognition of the challenges of ‘real life’ complexity and uncertainty in delivering patient-centred care.
• Students would like SDM to be more explicit across the curriculum and requested a mark scheme that reflects assessment of SDM skills.

Teaching staff identified both challenges and opportunities in relation to the points raised by students, when mapping existing and future SDM teaching across the curriculum.

What will happen next?

Actions as a direct result of this project were:

1. To update the information about Shared Decision-Making on the medical school undergraduate curriculum website by March 2024.
2. To incorporate SDM as the ‘final step’ in the existing framework for communication skills training about applying evidence in practice.
3. To introduce the use of a SDM peer / supervisor evaluation tool during communication skills teaching (to be piloted with year 3 students).
4. To negotiate adding phrasing to the Case Based Discussion assessment form (and/or mini-CEX assessment forms for year 5 students) to prompt discussion and assessment on aspects of SDM.
5. To incorporate reflection on SDM placement experiences, peer and supervisor observation and placement assessments into Professional Development Group activities.

The student and staff workshops were well attended, informative and have achieved the objectives of this project; to gauge student and staff experiences in order to improve the delivery of SDM training in the undergraduate curriculum. The project team are well placed to disseminate, and effect change as a direct outcome of this work. Our findings will be communicated to staff in key positions of influence.

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