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Objective Training to improve physicians’ shared decision making (SDM) competencies with proven effectiveness and efficiency is rare. This study evaluated the brief in situ training module ‘doktormitSDM’. Methods In a multicenter RCT, each physician recorded four consultations, each of which included a diagnostic or treatment decision (N = 152 consultations from seven medical specialties). The doktormitSDM training module included two video-based individual coaching sessions (15 min) at the physicians’ workplaces, supplemented by a manual and a video tutorial. Primary endpoint was the compound measure SDMmass (based on the MAPPIN’SDM system) which incorporates patient and observer perceptions of involvement and doctor-patient concordance on perceived involvement. Results SDMmass increased significantly in the intervention group compared to the controls (effect size 0.58; p= 0.05; t -test). This effect tended to persist at follow-up (effect size 0.63; p=0.06). Patients’ perceived involvement increased accordingly (effect sizes 0.9/.58; p=0.01/.07). Conclusion The doktormitSDM training module is effective and efficient at improving SDM competencies. This is the first SDM training to be evaluated with a compound measure simultaneously considering doctor, patient and observer ratings. Practice implications Owing to its very brief form and its reference to the doctors’ own consultation videos, the doktormitSDM training module meets clinicians’ needs and time constraints.

Norway has traditionally high standards regarding civil rights particularly emphasizing equal access to societal resources including health care. This background and the health care system's centralized national organization make it perfectly suited for implementation of shared decision making (SDM). In recent years, great efforts have been made by policy- makers, regional health authorities and not least the patients to facilitate a process of change in health communication culture. SDM is currently even given highest priority in health care strategies on all system levels. SDM has been structurally implemented, e.g. by including corresponding guidance in the standard patient pathways. Moreover, SDM is established as an element of service on the national health portal hosting a constantly increasing number of decision aids. Essentially the Norwegian Knowledge Center for Health Services contributes by searching and providing information for use in decision aids. Implementation is now being rolled out unit by unit for a list of medical problems as a series production of SDM using decision aids and health professional training. Importantly, production of SDM begins and succeeds as a soundly structured communication with both clinical environments and patients. However, as communication training has not been implemented before now, there are no data demonstrating sufficient realization of SDM in current health care. Beyond making reasonable use of scientific achievements, the Norwegian movement's secret of success is the simultaneous commitment of all actors of the health system to a common idea.

Background Natalizumab (NAT) is associated with the risk of progressive multifocal leukoencephalopathy (PML). Risk stratification algorithms have been developed, however, without detectable reduction of PML incidence. Objective To evaluate to which extent patients and physicians understand and accept risks associated with NAT treatment. Methods Prospective observational cohort study in German MS centers (n = 73) among NAT-treated MS patients (n = 801) and their neurologists (n = 99). Patients included in this study had mean disease duration of 10.2 years and a mean NAT treatment duration of 24 months. Results More than 90% of patients and physicians voted for shared decision making or an informed choice decision making approach. Patients and physicians perceived a similar threat from MS as serious disease and both overestimated treatment benefits from NAT based on trial data. Men perceived MS more severe than women and perception of seriousness increased with age in both groups and in patients as well with increasing disability. Although patients evaluated their PML risk higher, their risk acceptance was significantly higher than of their neurologists. Risk stratification knowledge was good among neurologists and significantly lower among patients. Conclusion While patients and physicians seem to have realistic risk perception of PML and knowledge of risk stratification concepts, the threat of MS and the perception of treatment benefits may explain the ongoing high acceptance of PML risk.

Objective To validate the Norwegian version of MAPPIN'SDM observer scales with regard to reliability, accuracy and the extent to which the scales include the essentials of the shared decision-making concept. Methods Three MAPPIN'SDM scales, focusing on the skills of doctor, patient and dyad, were applied to audiovisual records of 35 decision sequences. Inter-rater reliabilities were determined based on kappa coefficients. Sensitivities and specificities were calculated with regard to an expert reference standard. Convergent validities were calculated with the OPTION 5 scale. MAPPIN'SDM was qualitatively compared to OPTION5 using Makoul & Clayman's Integrative Model structure. Results Inter-rater reliabilities were high on average over 11 items in each of three observer scales (MAPPIN doctor =0.77, MAPPIN patient =0.82, MAPPIN dyad =0.77). Patient involvement was detected accurately (MAPPIN dyad : mean sensitivity/specificity 93/91%). Comparison with OPTION 5 showed weak to moderate correlation (Spearman's ρ/p-value: MAPPIN doctor :=0.44/0.009, MAPPIN patient : 0.38/0.024, MAPPIN dyad 0.40/0.016) and little content overlap. Conclusion MAPPIN'SDM norge is capable of assessing SDM highly reliably and accurately. Divergence from OPTION 5 reflects explicit disagreement regarding the concept's assumptions. Practice implications MAPPIN'SDM norge is ready for use in Norway. In-depth debate on the SDM concept's essentials is urgently needed.

Summary Objective Shared decision making (SDM) between patient and physician is an interpersonal process. Most SDM measures use the view of one party (patient, physician or observer) as a proxy to capture this process although these views typically diverge. This study suggests the compound measure SDM MASS ( SDM M eeting its concept's ASS umptions) integrating these three perspectives in one single index. Methods SDM MASS was derived theoretically and compared empirically to unilateral perspectives of patients, physicians and observers by application to a data set of 10 physicians (40 consultations) receiving an SDM training. Results The constituting parts of SDM MASS were highly reliable (Cronbach's alpha .94; interrater reliability .74-.87). Unilateral appraisal of training effects was divergent. SDM MASS revealed no effect. Conclusion SDM MASS combines noteworthy information about SDM processes from different viewpoints and thereby delivers plausible assessments. It could overcome immanent shortcomings of unilateral approaches. However, it is a complex measure needing further validation.

Objective To study the implementation of a patient education program on relapses and relapse therapy into routine care. Methods 31 health care professionals took part in a one day train-the-trainer program (TTTP) and subsequently 261 persons with MS (pwMS) took part in the education program. Evaluation was carried out in trainers and pwMS. Results Participants (health professionals) in the TTTP understood the program's main goals and reported that the TTTP enabled them to successfully perform the program. The majority of participants in the program (pwMS) understood the core messages. Also, they showed increased risk knowledge and increased decision autonomy preferences. Treatment decisions were reported as autonomous or as “informed choice” in 49%, and as “shared decisions” by 45%. Overall, effects were less marked compared to the results of the underlying randomized-controlled trial. Conclusion PwMS! appreciate evidence-based information about relapse management and view the unbiased presentation of scientific uncertainty as a chance for decision autonomy. Practice implications The implementation study confirms the program's transferability into clinical practice.

Shared decision-making (SDM) has the potential to overcome outdated social role models in the health care system. The concept, however, adheres to archaic epistemological assumptions as can be inferred from the rudimentary stage of the measurement methods used and from the information monopoly that the physician still holds in this concept. Advantages of an up-to-date model of knowledge for understanding and operationalising SDM are outlined. To this purpose, essential definitions of the concept are reflected in terms of epistemology. Accordingly, information emerges through a process of social construction. Likewise, interpersonal relations do not represent a static condition; rather, they develop anew with each interaction. Therefore, constructs suitable to focus on dyadic interaction processes can be used as indicators of sharing in SDM. Theories and methods of the interpersonal paradigm are advocated.