Framework for teaching and learning informed shared decision making Commentary: Competencies for informed shared decision making Commentary: Proposals based on too many assumptionsleaflets for patients, Smith emphasised the time it takes to produce clear, unambiguous material that patients will use. In addition to following validated quality criteria, writers should take patients' information needs into account and be aware of how people will read what they have written. 21 22 This will require involving patients in developing and testing materials. 10 Before embarking on this lengthy process, however, a first step is to check if high quality information already exists.
Active patient involvement in the education of health professionalsCONTEXT: Patients as educators (teaching intimate physical examination) first appeared in the 1960s. Since then, rationales for the active involvement of patients as educators have been well articulated. There is great potential to promote the learning of patient-centred practice, interprofessional collaboration, community involvement, shared decision making and how to support self-care. METHODS: We reviewed and summarised the literature on active patient involvement in health professional education. RESULTS: A synthesis of the literature reveals increasing diversity in the ways in which patients are involved in education, but also the movement's weaknesses. Most initiatives are 'one-off' events and are reported as basic descriptions. There is little rigorous research or theory of practice or investigation of behavioural outcomes. The literature is scattered and uses terms (such as 'patient'!) that are contentious and confusing. CONCLUSIONS: We propose future directions for research and development, including a taxonomy to facilitate dialogue, an outline of a research strategy and reference to a comprehensive bibliography covering all health and human services.
Putting informed and shared decision making into practiceOBJECTIVE: To investigate the practice, experiences and views of motivated and trained family physicians as they attempt to implement informed and shared decision making (ISDM) in routine practice and to identify and understand the barriers they encounter. BACKGROUND: Patient involvement in decision making about their health care has been the focus of much academic activity. Although significant conceptual and experimental work has been done, ISDM rarely occurs. Physician attitudes and lack of training are identified barriers. DESIGN: Qualitative analysis of transcripts of consultations and key informant group interviews. SETTINGS AND PARTICIPANTS: Six family physicians received training in the ISDM competencies. Audiotapes of office consultations were made before and after training. Transcripts of consultations were examined to identify behavioural markers associated with each competency and the range of expression of the competencies. The physicians attended group interviews at the end of the study to explore experiences of ISDM. RESULTS: The physicians liked the ISDM model and thought that they should put it into practice. Evidence from transcripts indicated they were able to elicit concerns, ideas and expectations (although not about management) and agree an action plan. They did not elicit preferences for role or information. They sometimes offered choices. They had difficulty achieving full expression of any of the competencies and integrating ISDM into their script for the medical interview. The study also identified a variety of competency-specific barriers. CONCLUSION: A major barrier to the practice of ISDM by motivated physicians appears to be the need to change well-established patterns of communication with patients.
Continuing medical education: Changes in health care and continuing medical education for the 21st centuryA revolution in health care is occurring as a result of changes in the practice of medicine and in society. These include changing demographics and the pattern of disease; new technologies; changes in health care delivery; increasing consumerism; patient empowerment and autonomy; an emphasis on effectiveness and efficiency; and changing professional roles. These are the challenges which will face the medical profession in the 21st century and to which continuing medical education must respond.
### Demographics and the pattern of disease
In 20 years' time the proportion of most rich countries' populations aged 65 and over will have doubled to around 20-25%. Old people today consume about a third of total health care spending; if present trends continue, by the year 2000 they will be consuming half.1 The consequences will be a shift in the need for preventive and curative health care in the direction of the chronic health problems of older people and a large increase in demand for care of very frail or ill dependent elderly patients. There will be even greater pressures to cap spiralling healthcare costs.
#### Summary points
The education system must be better able to respond to rapid changes in the outside world and involve employers and users of health services
The culture of the education system, now largely shaped by performance in examinations and emphasis on factual content, must be changed to one which values self directed learners and problem solvers
There is a need to improve the effectiveness of continuing medical education, such as developing better programmes on doctor-patient communication and interprofessional continuing education
No major changes in overall patterns of morbidity are expected, but some health problems will increase. Health loss areas will include the widening of social class disparities, increasing alcohol consumption and drug addiction, and increasing numbers of cases of senile …
Patients as educators: Interprofessional learning for patient-centred careBACKGROUND: Patients with chronic conditions have unique expertise that enhances interprofessional education. Although their active involvement in education is increasing, patients have minimal roles in key educational tasks. A model that brings patients and students together for patient-centred learning, with faculty playing a supportive role, has been described in theory but not yet implemented. AIMS: To identify issues involved in creating an educational intervention designed and delivered by patients and document outcomes. METHOD: An advisory group of community members, students and faculty guided development of the intervention (interprofessional workshops). Community educators (CEs) were recruited through community organizations with a healthcare mandate. Workshops were planned by teams of key stakeholders, delivered by CEs, and evaluated by post-workshop student questionnaires. RESULTS: Workshops were delivered by CEs with epilepsy, arthritis, HIV/AIDS and two groups with mental health problems. Roles and responsibilities of planning team members that facilitated control by CEs were identified. Ten workshops attended by 142 students from 15 different disciplines were all highly rated. Workshop objectives defined by CEs and student learning both closely matched dimensions of patient-centredness. CONCLUSIONS: Our work demonstrates feasibility and impact of an educational intervention led by patient educators facilitated but not controlled by faculty.