Shared decision-making in medical education – a systematic review

Shared decision-making (SDM) is a collaborative process in which healthcare professionals and patients cooperate to make informed decisions about care and treatment options. It integrates clinical evidence with the patient's values and preferences [1]. SDM is particularly relevant in preference-sensitive clinical decisions. This applies to situations in which multiple medically appropriate options exist and the optimal choice depends on how patients value the associated risks and benefits [2]. In such contexts, a mutual recognition that more than one acceptable choice exists creates favourable conditions for SDM.

Although often associated with the broader idea of patient-centred care (PCC), SDM refers more specifically to the communicative and cognitive processes through which medical decisions are made collaboratively. Whereas PCC encompasses general attitudes such as empathy, respect and responsiveness, SDM focuses on the interactional practices of deliberation and choice. Making this distinction helps clarify how SDM should be taught and assessed in medical education [3].

Nevertheless, SDM remains difficult to implement. Clinicians may be reluctant to acknowledge uncertainty [4] or revert to directive styles under time pressure [5], whereas patients may feel uneasy in the absence of a single “right” answer or prefer to leave the decision to the physician [6].

SDM has been shown to enhance patient knowledge, increase satisfaction and improve alignment between treatment and patient values. Teaching future clinicians to engage with SDM is therefore an important aspect of their education. Learning to engage in SDM involves both evidence-based reasoning, such as evaluating risks and benefits, and communication skills, including active listening, open-ended questioning and eliciting patient preferences [7]. Activities such as simulations, role-play and case-based discussions have been used to teach SDM, though evidence of their impact remains mixed [8]. How best to teach and assess SDM competencies in medical education remains a matter of debate.

This review is motivated by the limited evidence on which teaching methods most effectively develop SDM skills in medical students and by the lack of validated assessment strategies. These challenges are further compounded by implementation difficulties and variation in how SDM is integrated across medical curricula worldwide.

This review therefore addresses the following research questions:

- What teaching methods are most effective in helping medical students develop SDM competencies?

- How can assessments reliably measure students’ skills in SDM during clinical training?

Addressing these questions is essential for developing evidence-based educational strategies and ensuring that SDM becomes a core competency for all medical graduates.

Methods

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [9]. Studies were identified through structured searches in PubMed, Embase and Scopus. The initial search was conducted between 6 and 16 November 2024 and repeated between 31 July and 6 August 2025 to capture newly published material. The search strategy combined the terms “shared decision-making” and “medical students” and was limited to publications from 2014 to 2025.

Duplicates were eliminated using EndNote, with further verification by the first author through review of titles and abstracts. Screening was carried out by the first author, who reviewed all titles and abstracts and subsequently assessed the full texts of potentially eligible studies against predefined inclusion and exclusion criteria. For 20 uncertain cases, both authors reviewed the full texts independently and resolved discrepancies by consensus. All potentially eligible full texts were retrieved via the university library. Most exclusions were due to an incorrect study population or a lack of focus on SDM.

Studies were eligible if they described an educational intervention involving SDM, included medical students as the primary study population, and reported outcomes related to SDM competencies. For mixed-learner groups, only studies that reported outcomes separately for medical students were included.

The exclusion criteria were no SDM component, no medical students or no SDM-related outcomes for medical students. Studies with mixed-learner groups (e.g. nursing or allied health) were excluded if medical student outcomes could not be isolated. Non-peer-reviewed publications (e.g., conference abstracts and editorials) and non-English articles were also excluded; no translations were attempted. The overall selection process is shown in the PRISMA flowchart (Figure 1).

The methodological quality of included studies was assessed using an adapted version of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework, applied at the study level. Articles were rated as of high, moderate, low or very low quality according to five criteria derived from the Cochrane Handbook: risk of bias, inconsistency, indirectness, imprecision and publication bias. No studies were excluded based on quality; rather, these ratings informed the weighting and interpretation of the findings in the synthesis [10].

Results

A total of 23 articles were included to answer the review question (Table 1). The included studies represented a variety of designs: eight educational intervention studies [11-18], five randomised controlled trials [19-23], four quasi-experimental studies [24-27], three observational studies [28-30], one descriptive study [31], one qualitative study [32] and one mixed-methods study [33].

Teaching methods

Studies used a range of approaches to teaching SDM. The most common was role-play, either with standardised patients (SPs) [13, 15, 16, 26-30] or in peer-to-peer settings [11, 12, 14, 20, 21, 24, 31], sometimes supplemented by group discussions or practical exercises [11, 12, 21, 22, 31].

Other formats included virtual patients [17, 33], structured reflections [32] and multimodal designs, such as video-observed objective structured clinical examinations (OSCEs), e-learning modules or blended learning [20, 22, 23]. Online delivery was also trialled, including comparisons of face-to-face versus online role-play [26], preparatory modules followed by group discussions [20] or SP encounters via videoconference [16].

Innovative elements involved translation of medical documents into plain language [25], narrative testimonials versus fact-based texts [19], and direct patient involvement, where students engaged with individuals sharing their lived experiences [18].

Assessment strategies

Most studies relied primarily on self-reported surveys assessing perceived skills, confidence, and attitudes [11, 12, 14-17, 19, 21, 24, 26, 30-33]. These were usually structured questionnaires; some also included qualitative reflections, such as thematic analysis of e-discussions [32].

Performance-based measures were also applied, including SP encounters and structured evaluations of consultations [13, 14, 18, 22, 23, 25-29]. Approaches ranged from OSCEs with communication scenarios [28] and video-observed exams rated by blind reviewers [22] to videotaped consultations evaluated with structured rubrics [13, 26, 27, 29] and written care plans scored for patient involvement [18].

Several studies strengthened methodological rigour by applying validated instruments, including the scale for SDM performance [14, 23, 25], the MAPPIN’SDM observer scale [20], the Jefferson Empathy Scale [13] and the Four Habits coding scheme [21]. Some also combined self-reported and performance-based measures to enhance validity [20-23], for example, by linking survey outcomes to consultation ratings or by integrating knowledge tests, situational judgment tasks and observer assessments.

Outcomes

Outcomes were reported across four main domains: knowledge and attitudes, skills and performance, confidence, and learner satisfaction, with a few studies also examining sustained effects.

Several studies reported significant gains in knowledge and judgment ability [15, 20, 22, 23, 31], with Geiger et al. showing improved concordance with expert ratings [20] and Leblang et al. demonstrating high accuracy on knowledge items [31]. Attitudinal shifts were also observed as students placed greater decisional weight on patients and viewed SDM as more important after narrative exposure [19] or reported increased intention to apply SDM in future practice [17, 32, 33].

Improvements in performance-based outcomes were frequently documented. Enhanced SDM-related behaviours were seen in OSCE or SP encounters [14, 27, 28], in risk communication [22] and in problem definition and option discussion [25]. Video analysis confirmed stronger empathy and self-management behaviours [21], whereas written care plans revealed greater integration of patient voice [18]. Several studies showed strong performance on SP checklists and rubrics, though occasionally without alignment with faculty ratings [29].

Self-reported confidence and communication skills improved consistently [11, 12, 15, 16, 26, 30], often with students highlighting role-play and SP encounters as impactful. Learner satisfaction was high across most interventions, with sessions rated positively for realism, usefulness and relevance [16, 17, 24, 30]. Finally, a more limited number of studies demonstrated sustained or follow-up effects, including long-term retention of risk communication skills [22] and stable confidence levels months after training [30].

Discussion

Interpretation of findings

Teaching strategies to improve SDM behaviours varied greatly among the included studies.

Role-play with peers or SPs emerged as the predominant strategy across interventions [11-16, 21, 22, 24, 26-31]. Its pedagogical strength lies in an active, experiential learning format that allows students to practice SDM skills and experiment with different approaches in a safe environment. However, whereas role-play enhances self-reported confidence and observed communication skills [21, 24, 28], it remains uncertain to which extent these improvements translate into authentic clinical encounters, where patient complexity and time pressure may challenge transferability, raising questions of external validity.

Digital and online interventions [17, 25, 33] highlight the scalability and efficiency of digital teaching but raise questions about whether conceptual knowledge alone translates into applied SDM skills. Blended approaches [12, 23] have sought to address this by combining digital modules with experiential role-play; however, it remains unclear which component drives the observed improvements. Lin et al.’s comparative study suggests that well-designed online formats can achieve outcomes comparable to face-to-face formats, but its limited external validity and lack of long-term follow-up restrict conclusions about sustained competence [26].

Beyond role-play and digital training, innovative strategies such as narrative exposure [19], structured reflection [32] and patient involvement [18] highlight that SDM competencies extend beyond technical skills to encompass values, empathy and orientation toward patient partnership. Across studies, consistent improvements were observed in knowledge, attitudes, confidence and learner satisfaction, although performance-based outcomes were less consistently demonstrated and not followed in clinical practice. Importantly, findings from Induru et al. [29] revealed discrepancies between students’ self-assessments and evaluations by SPs, underscoring the need for multi-source, validated assessment strategies. Whereas most included studies were from Europe and North America, comparable results from Taiwan suggest that these approaches may be transferable cross-culturally, though further work in diverse contexts is needed [26].

The choice of assessment strategy further shaped the strength of findings. Some studies relied primarily on self-reported outcomes [11, 21, 33], which are prone to overestimation and may reflect perceived rather than actual skills. Retrospective pre-post designs [12] have been suggested as a refinement to reduce ceiling effects. By contrast, studies employing validated, performance-based tools such as the OPTION scale [23, 25], MAPPIN’SDM [20] or COMRADE/MPI [26] provided stronger evidence of genuine SDM competence. These instruments allow for standardised and objective measurement, but were inconsistently applied across studies, complicating comparability. In relation to the research questions, although heterogeneity limits firm conclusions, experiential teaching methods such as role-play, simulation and structured reflection appear most promising for supporting SDM skill development among medical students. Reliable assessment will likely require validated, performance-based tools and multi-source evaluations.

Strengths and limitations

This review provides a comprehensive synthesis of SDM training interventions for medical students, drawing on evidence from varied educational contexts, teaching strategies and assessment methods. By including studies across different stages of medical education, formats (e.g., simulation, didactic teaching, role-play and online learning) and outcome measures, it offers a nuanced picture of the heterogeneity in how SDM is taught.

Several studies were at a high risk of selection bias due to recruitment via websites, conferences or elective courses [11, 17, 19, 27, 30, 33]. Such approaches tend to attract students who are already motivated towards SDM, thereby inflating outcomes and limiting generalisability. In contrast, studies embedded in mandatory courses or integrated curricula [12, 24, 26, 28] reduced the risk by including students with more varied baseline motivation and competence. Still, even compulsory designs were affected by attrition and non-response (e.g., Ship et al., 38% response rate [12]), which may compromise representativeness. In summary, high-risk studies may overestimate effectiveness, whereas lower-risk studies provide stronger evidence for broader applicability.

Another limitation was the lack of long-term follow-up. Most studies assessed outcomes immediately after the intervention, leaving it unclear whether gains in knowledge, skills or attitudes persisted into clinical practice. A few exceptions suggest training effects can endure: Dray et al. reported maintained confidence at seven months [30], Koch et al. demonstrated sustained improvement in risk communication at 30 weeks [22] and Sawatzky & Kline found that students exposed to a patient-led programme in year one continued to prioritise patient perspectives and use diagnostic testing more judiciously three years later [18]. While encouraging, these findings remain constrained by small samples, voluntary participation and indirect outcome measures. More rigorous longitudinal designs are needed to determine whether training translates into lasting competence.

The review itself has limitations. The search was restricted to PubMed, Embase and Scopus, which may have narrowed coverage. Screening was conducted by the first author, using predefined criteria, with uncertain cases (n = 20) discussed and resolved jointly by both authors. Only English-language studies were included, raising the possibility of language bias; however, only three non-English articles were excluded at full-text reading, suggesting minimal impact. Conference abstracts and non-peer-reviewed publications were excluded, reducing comprehensiveness but ensuring sufficient methodological detail and quality. Finally, mixed-population studies were included only when medical student outcomes were reported separately, ensuring that the findings specifically reflect this target group.

Further directions

Future studies should employ more rigorous designs to address current limitations in SDM training research. Larger, multi-centre randomised trials with standardised interventions are needed to clarify which teaching strategies yield lasting gains. Longitudinal designs are particularly important to determine whether improvements in knowledge, confidence and communication skills persist in clinical practice.

One study highlights the value of structured, standardised approaches to SDM training for healthcare professionals and underscores the need for collaboration across countries and disciplines to support broader adoption [34]. To strengthen comparability, researchers should use validated, performance-based assessment tools, ideally alongside self-report and multi-source evaluations from SPs and faculty. Developing a core outcome set for SDM training in medical education could further improve consistency across studies.

For educators, current evidence supports active learning strategies such as role-play with peers or SPs, combined with reflective exercises and structured feedback, which consistently enhance confidence and skills. Online and blended formats show promise for scalability but should be paired with experiential practice to ensure applied competence. Future curricula should also address known barriers, such as time constraints and managing uncertainty, by embedding SDM practice into realistic, challenging scenarios.

In clinical practice, studies using the OPTION scale have consistently shown that the extent of SDM remains limited [35]. This highlights the importance of integrating SDM-focused communication training into medical education to better prepare future doctors for PCC.

Conclusions

This systematic review demonstrates that a wide range of strategies have been employed to teach SDM in undergraduate medical education, with role-play and simulation emerging as the most consistently effective methods for building skills and confidence. Innovative formats, such as narrative exposure and reflective exercises, may offer additional value in shaping attitudes and empathy, though evidence remains limited.

Across studies, the validity of findings was limited by reliance on self-reported outcomes and inconsistent use of validated instruments. Performance-based assessments, particularly when combined with multi-source evaluations, provide stronger evidence of competence but were applied inconsistently. Long-term effects were rarely measured, and it remains unclear whether training translated into sustained practice.

In conclusion, the evidence highlights the promise of experiential and patient-centred approaches, while underscoring the need for more rigorous, standardised and longitudinal research to establish effective and reliable strategies for embedding SDM as a core competency in medical education.