
==== Front
Perm J
tpj
tpj
The Permanente Journal
1552-5767
1552-5775
The Permanente Press

39054825
10.7812/TPP/23.153
TPJ-23-153
Brief Report
A Practical Approach for Developing Shared Decision-Making Knowledge, Skills, and Capability for Busy Health Care Practitioners
http://orcid.org/0000-0002-7399-622X
Oliver Brant J PhD, MS, MPH, FNP-BC, PMHNP-BC 1 2 3
Fallon Ingram Michele BS 4
Rudell Elaine MHA, CHCP 4
1 Departments of Community & Family Medicine, Psychiatry, and the Dartmouth Institute for Health Policy & Clinical Practice at the Geisel School of Medicine at Dartmouth, Hanover, NH, USA
2 Office of Care Experience, Value Institute, Dartmouth-Hitchcock Health, Lebanon, NH, USA
3 Chronic Health Improvement Research Program at Dartmouth Health, Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
4 Projects In Knowledge Powered by Kaplan, Ft Lauderdale, FL, USA
Brant J Oliver, PhD, MS, MPH, FNP-BC, PMHNP-BC brant.j.oliver@dartmouth.edu
2024
26 7 2024
28 3 262269
© 2024 The Authors.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Published by The Permanente Federation LLC under the terms of the CC BY-NC-ND 4.0 license https://creativecommons.org/licenses/by-nc-nd/4.0/.

Abstract

Background

There has been substantial development of shared decision-making (SDM) methods and approaches in the past few decades, but despite this, building capability and scaling application of SDM in clinical practice remains a challenge. Here the authors describe the development and initial experience with a new virtual Practical Approach continuing education program for busy practicing clinicians who care for people with complex, chronic, and costly conditions who are frequently faced with preference-sensitive decisions. This program was designed to provide plain language training in SDM for real-world clinical practice using an easy 4-step approach that does not require prior training or formal education in SDM theory or methods.

Methods

The authors describe the development of the Practical Approach program using established evidence-based principles. The program was piloted in 4 different settings across 2 chronic conditions. Qualitative interviews of program participants were conducted to observe SDM attitudes and observed performance in repeated case-based simulation role-play exercises to assess knowledge and skills performance.

Results

The authors observed improved and more realistic SDM attitudes in qualitative interviews with program participants after exposure to the program compared to baseline, and they similarly observed improved knowledge and skills demonstrated in sequential simulations conducted as participants were exposed to the program. Post-program focus groups revealed that participants perceived the program to be feasible, acceptable, and useful.

Conclusions

Initial experience with the Practical Approach program suggests that it may beneficially affect basic SDM knowledge, skills, and attitudes in busy practicing clinicians who are novices in SDM. It also has demonstrated initial feasibility, utility, and acceptability.

Disclosures The Practical Approach program was developed for and is copyrighted by Projects In Knowledge Powered by Kaplan, a health care continuing education subsidiary of Kaplan.

FI and ER have no relevant financial relationships to disclose. BO received limited support from Projects In Knowledge Powered by Kaplan to provide specific methodological and educational consulting to support the development, facilitation, and evaluation of the Practical Approach program.
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pmcIntroduction

Health care decision-making is a complex activity; especially so in complex, chronic, and costly (3C) conditions, such as multiple sclerosis (MS), inflammatory bowel disease, cancers, and many others. Preference-sensitive decisions present especially in 3C conditions—meaning that there is no single evidence-based treatment or care option available for the person, condition, and situation at hand.1 Shared decision-making (SDM) is indicated in preference-sensitive decisions and can be defined as a “process of communication in which clinicians and patients work together to make optimal health care decisions that align with what matters most to patients.”2 SDM can help patients and their treating practitioners reach decisions together that are higher quality (better informed and aligned with preferences and values), result in lower decisional conflict (less cognitive dissonance about and more confidence in the decision), encourage health care co-production (patients and practitioners co-creating care together), and can improve treatment adherence and outcomes.1

There are a wide variety of evidence-based, rigorous general models developed for SDM implementation with varying degrees of effectiveness and feasibility,3 including the “Three Talk Model,”4 the Seek, Help, Assess, Reach, and Evaluate (SHARE) approach,5 and adaptations for specific populations, such as palliative cancer care.6 However, many barriers to SDM practice remain despite the ongoing development of the field and a growing evidence base supporting its potential. SDM training is not yet a normal part of most standard health professions’ clinical education programs, and it is only beginning to penetrate residency and fellowship programs, resulting in a growing need for continuing education programs to be designed to build knowledge skills and capability for busy frontline clinicians in practice. Formal SDM training programs for use in health professions’ education programs is needed, and there is developing dialogue about how to best teach SDM.7,8 In the continuing education setting specifically, SDM training must be made practical and accessible so that it will be used by busy frontline practitioners and will not be perceived as too burdensome or too difficult to understand for patients.8

Here the authors describe a new practical approach suited for busy health practitioners that can be employed virtually in continuing education settings. This program includes an easy 4-step process that can be employed in a standard clinical visit and taught in a virtual environment and involves didactic and simulation activities. It also emphasizes the use of plain language (minimizing technical jargon), uses repeated brief educational exposures in order to reinforce learning and accommodate practitioners’ busy schedules, and does not require theoretical knowledge about SDM or prior completion of formal academic or continuing medical education training to participate. Finally, simulation case role plays, assessments, and feedback are all facilitated virtually.

Methods

An organization with expertise in developing and facilitating continuing education programs for health practitioners and an academic group with expertise in SDM and health care improvement collaborated to develop the Practical Approach program and pilot it at 4 health care centers. The authors applied experiential and simulation-based learning principles for adult learners9,10 to create a SDM continuing education program that could be administered virtually via synchronous and asynchronous mechanisms. The authors based the program on 3 principles required for successful SDM: (1) “clear, accurate, and unbiased information;” (2) practitioner expertise in communicating and tailoring that information for individual patients; and (3) inclusion of patient values, goals, preferences, and concerns. 2 Great emphasis was also placed on utilizing evidence-based tactics that would optimize engagement and potential for co-production, including co-learning between patients and practitioners, shorter educational exposures, and face-to-face virtual and in-person synchronous learning.11 The authors viewed engagement as including “. . . communication, decision-making, and partnerships . . . between clinicians and their patients.”11

The Practical Approach continuing education program

The authors articulated 88 practical domains of SDM decision quality derived from SDM essentials (Table 1),1–3 which, if practiced consistently, can facilitate achievement of the SDM principles: (1) reasonable options: practitioner determination of a parsimonious list of reasonable options to choose from which are appropriate for the patient, condition, and situation; (2) accessibility: the degree of access that the patient would have to each treatment choice (practical and financial); (3) decision style preference: how an individual prefers to make decisions and the degree to which that preference is practitioner or patient dominant; (4) knowledge about each of the options and identification of learning needs and styles; (5) tolerance: the amount of risk and burden an individual is willing to accept to get best results;(6) activation, engagement, and self-efficacy: orienting the process to match an individual’s orientation toward active involvement in their health, health care, and wellness; (7) a trade-off format to illustrate the comparative advantages and disadvantages of the options being compared; and (8) assessing readiness to make the decision and aligning the follow-up plan to match. Finally, the authors organized the 8 domains into a 4-step practical approach to SDM to provide an easy process for busy practitioners to follow in a logical sequence designed to identify options, assess knowledge and preferences, weigh trade-offs comparatively between options, and assess readiness to decide.

Table 1: Domains of decision quality in the Practical Approach program

Reasonable
options	Practitioner narrows list of options to a limited menu of reasonable options; the SDM process then focuses on this menu	
Decision style preference	Style preference is articulated and respected by patient and practitioner.	
Knowledge	Patient and practitioner have a shared working knowledge of the most important information involved in the decision.	
Risk/burden tolerance	Tolerances are discussed, articulated, and aligned with discussion of wellness options.	
Accessibility	Insurance coverage status and out-of-pocket expenses, as applicable, are understood and factored into the decision.	
Trade-off decisions	Trade-offs are made explicit, are articulated, and are understood by patient and practitioner.	
Readiness	Patient and practitioner feel confident and comfortable in making the decision.	
Activation, engagement, self-efficacy	Decision is realistically aligned with and encourages activation, self-efficacy, and engagement.	
SDM, shared decision-making.

The authors organized the educational program into 3 components that could be used in a modular fashion to facilitate the program: (1) a SDM didactic training video about the Practical Approach (30 min); a didactic training video on clinical knowledge and skills (60 min); and (3) a case role-play simulation exercise with real-time feedback (60 min), including practical evaluations of knowledge, skills, and attitudes (to assess feasibility, acceptability, and utility of the program). The authors developed separate materials and videos for practitioners and patients to meet their specific learning needs. Educational tools incorporated in these modules included a quick reference pocket guide (for use in actual clinical practice) and decision support tools and decision aids. The program was facilitated as a sequence of repeated learning exposures beginning with didactic education and followed by repeated simulation training, feedback, and reflection. Training materials addressed SDM, pros and cons of treatment options for a specific chronic disease, and practitioner–patient simulation case role plays demonstrating the Practical Approach in action. In the role-play scenarios, learners practiced SDM interactions using the Practical Approach with professional standardized patients following structured case scenarios and used the decision support tools and the quick reference guide on the Practical Approach. These tools were developed using US Food and Drug Administration prescribing information for treatments, and the tools and their use were covered in the didactic training videos and used during the simulation role-play exercises. Real-time feedback was provided directly following each simulation, which included learner reflections. The authors used a secure, Health Insurance Portability and Accountability Act–compliant, password-protected online platform12 to guide participants through the program and for access to all program materials and to track participant progress and outcomes.

The authors piloted the program in 4 health care centers. The programs varied greatly based on context, clinical population, and practical situation. In some pilots, both patients and multidisciplinary practitioners (physicians, nurse practitioners, nurses, social workers, pharmacists) were trained. In others, only practitioners were trained. In each program, each participant acted as their own control, comparing their baseline pre-program performance with their post-intervention interim (halfway point) and end-of-program performance. Focus groups were held after the completion of each pilot to report pilot findings to the group and obtain feedback to improve future programs. As a result, each program was iteratively and incrementally improved on the basis of observations of previous pilots following Agile prototype development principles.13

Pilot program assessments

The authors conducted real-world practical assessments of the Practical Approach pilot programs in various settings in 2 populations—MS and oncology. The authors invited practitioners and patients at health care centers to participate in the pilot programs based on stated practical need and interest in participation (convenience recruitment). The authors recruited participants for each program using a convenience sampling approach to enroll participants (see Table 2 for detail). Note should be made that all 4 programs enrolled practitioners and 2 programs also enrolled patients. The authors assessed the programs in 2 ways: (1) dual-rater assessments of observed role-play case study simulations using a standard competency scale for demonstrated proficiency in each of the 8 SDM quality domains, and (2) basic inductive thematic analyses of individual qualitative semi-structured interviews14 of each learner conducted pre-program, halfway through the program, and at the end of the program. The simulation role-play assessments included ratings of performance quality in each of the Practical Approach domains by 2 trained observers using a standard Likert rating scale and a consensus rating process. Using a 2-rater system, the simulation case role play was scored from 0 to 4 on a Likert-like scale (0% = 0; 25% = 1; 50% = 2; 75% = 3; 100% = 4).

Table 2: Characteristics and summary findings from 4 Practical Approach pilot programs

Program/pilot (years)	Setting and inclusion criteria	Participants	Observations/findings	
Swedish MS Center, WA,
USA
(2017–2018) 15 , a	Setting and population: Adult MS center, disease-modifying therapy decisions.
Inclusion criteria for practitioners: Physicians directly involved in the clinical management of patient with MS.
Inclusion criteria for patients: Adults 18 years of age with clinically confirmed MS seen at least once annually at the MS center, and consenting to participation per protocol requirements	Total N = 97
[physicians (n = 2)
patients (n = 95)]	Primary endpoint: SDM—Statistically significant improvement in the overall I Group median PAM and SDM scores (p < 0.0001); older subset of the I Group median PAM and SDM scores (p < 0.001 and p < 0.05, respectively); SPMS subset of the I Group median PAM and SDM scores (p < 0.05 and p < 0.001, respectively).
Secondary endpoints: PROs
—Statistically significant clinical improvements in the secondary endpoints (fatigue, depression, quality of life, and cognitive function) resulting from SDM, comparing the I Group vs the C Group, usually required a longer study duration of ~ 2–3 years.	
Smilow Cancer Care
Center, CT, USA
(2019–2020) 16 , b	Setting and population: Academic oncology center non-small cell lung cancer (NSCLC), immunotherapy treatment decisions
Inclusion criteria: Clinical practitioners involved in direct care of adults 18 years of age with NSCLC.	Total N = 6
[physicians (n = 2);
nurse (n = 1);
nurse practitioner (n = 1); pharmacist (n = 1);
social worker (n = 1)]	Training empowered all Yale NSCLC team members to show pre- to post-education improvement in SDM (34%–88%).
Areas of greatest improvement: (1) providing reasonable treatment options (+58%); (2) determining decision style preference—extent to which a patient wants to participate in the decision-making process (+76%); (3) determining a patient’s risk tolerance regarding treatments (+77%); and (4) determining a patient’s goals/preferences (+88%).	
Smilow Cancer Care
Center, CT, USA
Breast Cancer
(2021–2022) 17 , b	Setting and population: Academic oncology center (breast cancer), checkpoint inhibitor treatment decisions.
Inclusion criteria: Health practitioners directly involved in the care of adults 18 years or older with breast cancer.	Total N = 11
[physicians (n = 9);
nurses (n = 2)]	Training empowered the Yale Breast Cancer team to show pre- to post-education improvement in SDM case role-play scenarios, ranging from 16% to 39%.
Areas of greatest improvement: (1) determining decision style preference (+36%); (2) determining patients’ risk/burden tolerance (+32%); (3) determining patients’ activation, engagement, and self-efficacy (+34%); (4) determining trade-off decisions with patients (+39%); and (5) determining patients’ readiness to make a decision (+32%).	
Stony Brook MS Center,
NY, USA
(2021–2023) 18 , b	Setting and population: Academic MS center, wellness and symptom-management decisions.
Inclusion criteria for practitioners: Physicians directly involved in the clinical management of patient with MS.
Inclusion criteria for patients: Adults 18 years of age with clinically confirmed MS seen at least once annually at the MS center, and consenting to participation per protocol requirements.	Total N = 80
[physicians (n = 3);
patients (n = 77)]	Although underpowered, the study still showed some significant results. Although the number of practitioners was small, all showed improvement in case role-play scenario performance post-program exposure.
Qualitative semi-structured interviews of patients revealed: (1) case role-play training gave patients “permission”/confidence to ask their practitioners questions on topics of concern, and behavior to emulate, and (2) “commonly asked questions” provided a list that could be used to prepare for future office visits. Some indicated they had made changes to their diet and exercise routine.	
Note: Ethics reviews were conducted for each of the 4 pilots by the IRB at the program site.

a Approved as minimal risk human subjects research.

b Determined not to be human subjects research (exempt/quality improvement).

IRB, institutional review board; MS, multiple sclerosis; PAM, Patient Activation Measure; PRO, Patient-Reported Outcome; SDM, Shared Decision-Making; SPMS, Secondary Progressive Multiple Sclerosis.

Each of the 4 programs included qualitative interviews of clinician participants, and 2 of the programs included qualitative interviews of patients who experienced the SDM training exposure. Patients recruited for these interviews were selected using a randomized procedure. In the Yale non-small cell lung cancer program, a formal inductive thematic analysis approach was conducted by Hakim et al.19 This included 2 trained raters using a consensus process. In the Stonybrook MS program, a practical single-rater thematic analysis approach that was designed to provide a practical assessment of participant experience (feasibility, acceptability, and utility) was used.

Some programs were institutional review board (IRB)–approved for research study, although others were viewed as quality improvement projects not requiring IRB review. Research pilots that included patient participation employed research applications of these assessments that were augmented by validated questionnaires, such as the Decisional Conflict Scale (decision quality)20 and the Patient Activation Measure (patient activation and engagement),21 which were obtained pre- and post-program. Finally, whenever possible, the authors also conducted post-program focus groups with each learner cohort to learn about learner experiences, asking, for example, did patients come away from these programs feeling empowered to engage in discussions with practitioners about their health care and treatments to take a more active role in their health care? Did practitioners engage their patients in meaningful discussions about their disease and establish trust that can lead to better decisions and outcomes?

Ethics Reviews

The present study is a description of a program developed based on different but related programs conducted and observed at 3 different locations: 1) Yale (New Haven, CT); 2) Stonybrook MS Center (New York); and 3) Swedish MS Center (Seattle, Washington). The Yale programs did not meet the criteria for IRB review based on their classification process (instead, these qualified as quality improvement). The Swedish program was IRB reviewed and approved as minimal risk research. The Stonybrook program was IRB reviewed and determined not to qualify as human subjects research.

Results

A total of 21 health care practitioners and 172 patients participated across the 4 pilot programs (Table 2). The authors observed that participants demonstrated a favorable change in attitudes toward SDM as assessed via sequential qualitative interviews conducted over the longitudinal course of each program. The authors also observed improved evidence of knowledge in skills evidenced by improved behavioral performance in case role-play simulations conducted repetitively as the participants matriculated through the programs. Finally, the participants perceived good acceptability and feasibility of the programs as reported in focus groups conducted with program participants following the conclusion of each program.

Semi-structured qualitative interview assessments

The authors sought to learn about the educational experience of program participants before, during, and after participation in the pilot programs. The authors conducted structured qualitative interviews and thematic analyses of interview data.

Practitioners

Practitioners were assessed at baseline, at the interim time point (in selected programs), and at the end of the pilot utilizing qualitative semi-structured interviews and simulation case role plays. Practitioner interviews revealed that a number of them had made assumptions about their patients’ preferences, goals, and risk tolerance—without ever asking them. For example, 1 practitioner assumed that his elderly patient would be unwilling to take a more effective treatment because of its potentially serious side effects. After his training, the practitioner asked this patient about his risk tolerance and learned that the patient’s goal was to slow the disease process and was less concerned about side effects. Prior to training, many practitioners did not use “teach back” (a method where patients explain, in their own words, what their physician just told them) to make certain patients understood. Prior to training, most practitioners thought they did not have “time” to implement SDM methodologies in their patient discussions. However, after training, they could see that a team approach would be an important way to make SDM an efficient model. One practitioner reported that “SDM is a valuable tool . . . for quality of care and patient satisfaction.”

Patients

In each pilot that included patients (Table 2), a subset of patients was interviewed at baseline and at the end of the pilot. After the case role-play simulation and disease/disease management video training, patients in the subsets who were interviewed said they felt empowered and indicated it gave them “permission” and confidence to ask their practitioners questions that they were reluctant to ask before. Although many patients were asking their health care practitioner questions of interest for them before training, they felt they should not ask these questions, whereas after training, the patients felt they should ask questions. The video was designed to model an optimal communication approach to emulate. The video case role-play format was also ideal for patients to share with their caregivers, who might otherwise not understand issues concerning their disease. Many of the patients said they now have more open communications with their practitioners. The authors observed that some patients reported that they began taking better overall care of themselves by eating healthier diets and exercising more. Patients commented that they liked the remote format and tools that were provided, such as the tips cards that featured commonly asked questions. This helped them prepare for subsequent clinical care visits. A quote from one of the patients was illustrative: “. . . a very nice program that can help patients at any point in their health care journey.”

Synthesis

At the outset of these pilots, the authors observed some resistance from clinicians participating in the pilot. They viewed this training to be of little value because they had been practicing for years and believed that they knew what to do and perceived that they currently practiced SDM effectively. However, the learners reported realizing better insight about their current performance and opportunities for improvement during the program, and eventually developed better skills. They noted that a number of the program characteristics encouraged this, including: 1) real-time feedback on all of their simulation case role plays; 2) constructive, real-time, nonjudgmental performance feedback by the professional standardized patient and the content expert who observed the role play; and 3) remote access to all educational training on the online dashboard. Table 3 provides selected brief quotes from participants exemplifying reflections that the authors observed, and a systematic investigation reported by Hakim et al19 provides substantive qualitative analysis findings based on a study of participants from one of the oncology pilot programs.19 Perhaps most illustrative was a comment made by one of the most recalcitrant participants who, after completing the program, simply concluded that “. . . we all have something to learn.”

Table 3: Selected take away quotes from Yale team members at their post-program focus group session

Participant	Quote	
Physician #1	“SDM changed the way I interact with my patients.”	
Physician #2	“Patients need more time to process information before making a decision . . . do not rush the decision-making process.”	
Physician #3	“Real-time feedback is . . . critical . . . role play is different in your head than when you say it out loud.”	
Clinical pharmacist	“I would like to bring this information [SDM] back to my team of pharmacists to show them the process . . . it's . . . eye-opening.”	
Nurse practitioner #1	“Well designed pilot.”	
Nurse practitioner #2	“SDM training made me more mindful of patient concerns.”	

Simulation case role-pLay Assessments

Overall results of the pilot programs are given in Table 2. Simulation case role plays in each pilot included a practitioner, a professional standardized patient, and a moderator to guide the practitioner–patient discussion and were designed to demonstrate how well the practitioner was able to incorporate the Practical Approach methodology into patient interactions. Practitioners were evaluated throughout the simulation to determine whether the 8 domains of decision quality were addressed with the patient and to what degree (the domains reflected patient-centric areas of interest). Across all of the pilot programs, the practitioners showed statistically significant improvements from baseline to end of pilot in the following domains of excellence: 1) reasonable options; 2) trade-offs, and 3) readiness.

Discussion

The Practical Approach is a new continuing education program designed to introduce busy health care practitioners to basic knowledge and skills in SDM using a brief, virtual pedagogy featuring didactic education, repeated simulation role-play training with professional patients and real-time feedback, and integrated mixed methods assessments of knowledge, skills, and attitudes. The authors observations of the program across 4 pilot programs conducted across 2 complex chronic disease conditions suggest initial good feasibility, acceptability, and utility of this learning activity, especially in practitioners, from whom the preponderance of the evidence to date has been gathered. Limitations of these pilot programs include small sample size for practitioner participants, lack of detailed demographic information collected on participants, and nonrandomized program designs. These programs were designed for feasibility, emphasizing practical aspects over rigorous design when both were not simultaneously possible. Building upon these pilot experiences, future studies could be designed to address these limitations using longitudinal, randomized designs and larger samples.

Practitioner experience

Overall, participants reported that the methodologies and educational interventions in the pilots were feasible and acceptable and that they were practically useful in the practice setting. Although the pilots were conducted in different contexts, one being MS and the other being oncology, the baseline and end-of-pilot changes were similar. The results suggest that the methodology the authors developed is feasible because it can be done conveniently, using a virtual webinar-based format, and an online access system and dashboard. Practitioners perceived it to be very efficient (no need to travel) and user-friendly. The interventions were well received, even among practitioners who were in practice for many years, and more importantly, the methodology was a beneficial means of improving communication and decisions that align with the patients’ preferences and goals. Most participants came away from the learning activity feeling that they had developed an improved skill set for communicating with their patients and making preference-sensitive decisions.

Alexander et al22 conducted a formal descriptive assessment of performance outcomes for one of the oncology programs described in Table 2 and found substantial performance improvements in the Practical Approach application after program exposure.22 In the present study, the authors found that, in general, all 4 pilot programs findings were similar. The authors often observed at program outset that practitioners demonstrated a tendency to quickly jump toward determining the treatment choice for the patient without first discussing other options or determining patient preferences and learning needs. After exposure to the program, the authors observed a shift in behavior in most participants. The authors observed that the practitioner participants demonstrated more deference to the assessment of patient preferences and the provision of more support and time to process the information and that they tended to address preferences and learning needs prior to moving toward making a decision. Finally, as part of the training, practitioners were educated about decision aids and introduced to summary tips cards, the latter of which provided a summary of the Practical Approach and recommended steps to performing it. Some became adept at using them and demonstrated integration of their use in end-of-program simulation exercises.

Patient experience

Semi-structured interviews of a subset of the patients revealed that the educational intervention training gave them “permission” to ask their practitioners questions that they may never have asked prior to this education. The online dashboard used to organize the learning activity facilitated patients’ input on validated measure forms and also provided a virtual location where they could access and complete their didactic training. Patients expressed that they liked using the dashboard because it helped them keep organized and they could also share some of their training materials with their caregivers, who they felt could benefit from the information to better understand their disease and the complexity of the treatment decisions they were facing.

Conclusion

The authors’ Practical Approach is a new continuing education program designed for busy health care practitioners currently in practice without substantive training in SDM who are working with populations with complex chronic conditions and who frequently face preference-sensitive treatment decisions. This program could augment the growing array of SDM methods and strategies available in the field and may be particularly helpful in the continuing education space to address the learning needs of busy practicing clinicians who are novices in SDM and need an accessible introduction to SDM.

The Practical Approach program has demonstrated initial feasibility, acceptability, and utility in 4 pilot programs conducted across 2 chronic illness populations. Further research will need to be conducted to assess longitudinal effectiveness, implementation capability, and related population health outcomes. Additionally, if developed and assessed further, the Practical Approach would need to be studied comparatively with other established models and methods to determine where, when, how, and with whom it can be most effectively and efficiently employed. Currently, available evidence suggests that it may have a niche and potential value in the continuing education space for busy practicing clinicians who are SDM novices and seeking a disciplined practice of SDM as part of the clinical care they provide to their patient populations.

Author Contributions: BO provided the shared decision-making conceptual and methodological design of the Practical Approach program, participated as a facilitator and evaluator in the program, served as the lead author on the manuscript, and participated in all aspects of manuscript preparation and revisions. ER participated in the development of the program, and as a facilitator and evaluator, and in manuscript preparation and edits. FI participated in program development and in review and revisions.

Conflicting Interests: None declared

Funding: None declared

Data-Sharing Statement: Data are available upon request. Readers may contact the corresponding author to request underlying data.
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