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Patients increasingly want to participate in the decisions that are being made about their health. The value of patient involvement in healthcare is increasingly acknowledged. Shared decision making (SDM) is considered the preferred way of decision making. There is consensus amongst stakeholders (patients, clinicians, the Dutch government) that SDM should be common practice. However, there is a gap between theory and practice. Several challenges stand in the way of widespread use of SDM. Those challenges include insufficient content-specific knowledge and little understanding of SDM concepts amongst general practitioners (GPs). The current GP vocational training programs have little attention for SDM. To increase knowledge and skills, frequent exposure to SDM and frequent practice is crucial.

With the proposed project we aim to improve and increase the amount of SDM education in the GP vocational training program by embedding SDM within the existing education. Up to now, most research on SDM has focused on treatment decisions. We will broaden the scope by studying and developing educational materials for SDM in the diagnostic process. This is particularly relevant for GP where many consultations have a diagnostic nature and difficult decisions regarding diagnostic steps (i.e. referrals, tests) are made.

We propose novel studies to better understand SDM in the diagnostic process. We will use a variety of data sources and research methods to identify the most important and clinically relevant learning opportunities for GP trainees. Based on the proposed studies, we will develop evidence-based educational materials. We plan to develop the material in such a way that it can be embedded in existing educational programs of the GP vocational training.

The overall aim of the proposed project is to improve the GP vocational training by integrating evidence-based education on SDM in the diagnostic process in the existing education.

First, we will identify which diagnostic decisions in GP will benefit most from a SDM approach (study 1). SDM in the diagnostic process is still a new area of research and little is known about the situations that are most suitable for SDM. Malpractice claims in which there was a perceived lack of patient involvement are particularly suitable to identify SDM relevant situations, because they reflect those cases where a lack of SDM led to dissatisfaction or harm. These cases reflect clinically relevant situations,

and are therefore important learning opportunities for GP trainees.

Second, we will examine the role of content-specific knowledge and the tolerance of uncertainty in SDM (study 2). The diagnostic process is -much more than treatment decisions- characterized by uncertainty. Having insufficient content-specific knowledge and little tolerance of uncertainty may prevent GPs to use of SDM in the diagnostic process. Thirdly, we will experimentally test whether providing GP trainees with content-specific knowledge will facilitate SDM in the diagnostic process which will be tested in virtual consultations with real patients (study 3). This is an innovative approach providing insights into the potential effect of content-specific knowledge education on SDM and the vulnerabilities in the SDM process.

SDM by nature reflects the communication between the GP and the patient. The extent to which a patient is engaged in the SDM process and which communication strategies work well in a GP setting are important lessons to learn. By analyzing the consultations from study 3 using a qualitative conversation analysis approach, we will unravel the interactions between GP trainees and patients (study 4). We will identify triggers that suggest whether the patient is engaged in SDM. In addition, communication strategies that are efficient can be distilled from the video recordings, which will be incorporated in the educational materials.

The last part of the proposed project will exist of developing evidence-based educational material. The material will be based on the most relevant topics identified in study 1, and reflect the content-specific knowledge gaps and the vulnerabilities of the SDM process identified by study 2-3. Furthermore, it will contain the communication specific learning opportunities identified by study 4. The educational material will include a variety of clinical cases and can be used in different types of existing education (i.e. evidence-based practice, clinical reasoning, physician-patient communication).

With the proposed project a novel research area will be addressed and new scientific insights into SDM in the diagnostic process will be obtained. It will result in evidence-based educational material which can be used throughout the GP vocational training. SDM will therefore become an integral part of the GP vocational training.

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