Learning shared decision making in undergraduate medical education: a realist review

Shared decision making (SDM) balances patient preferences with clinical evidence but remains inconsistently practiced. Training physicians during undergraduate medical education (UME) is a proposed strategy, yet theoretical understanding of educational SDM interventions is lacking. We aim to understand how educational SDM interventions in UME work, in what circumstances and why. We conducted a realist review following RA-MESES standards. We developed an initial program theory through analysis of a scoping literature review and expert interviews. A systematic literature search across 11 databases then identified relevant studies, which were analyzed to uncover context-mechanism-outcome configurations (CMOs). These informed the development of a final program theory (FPT) through interpretative synthesis. From 17 studies, we identified 22 CMOs grouped into six themes: building a theoretical foundation, integrating theory and skills, congruence with clinical tasks, contextualizing SDM learning, stimulating professional identity formation and enablers. Our FPT describes that educational SDM interventions focused on building a theoretical foundation, integrating theory and skills and professional identity formation work when they are scaffolded, congruent with future clinical tasks and contextualized. A supportive learning environment, sufficient time allocation, faculty development and self-regulated learning enable the educational SDM interventions to work more effectively. Intended outcomes are motivation, self-efficacy, shared professional values and SDM competence. This realist review provides a theoretical framework on how educational SDM interventions in UME work, in what circumstances and why. Research is needed to test and refine our theory, especially to further explore how specific UME settings influence learning.