The Six Steps of SDM: linking theory to practice, measurement and implementation

Shared decision-making (SDM) has gained acceptance as a preferred and ideal method for medical decision-making.1 2 As SDM concepts and assessments initially focused on the clinical encounter, efforts to improve decision-making for patients initially did so, as well.3 This resulted in a plethora of patient-focused interventions (eg, patient decision aids)4 while lacking concurrent development of a systems-oriented approach to change the structural and procedural requirements of medicine for optimal implementation of SDM practice.5 ### Rationale and context for developing The Six Steps of SDM We developed The Six Steps of SDM to fill gaps in coordination among theory, measurement, interventions and implementation of SDM. That is, ideally, theory should drive both measurement and development of interventions (including skills training and tools such as decision aids), and therefore, influence implementation. However, SDM theories, assessments, decision tools and curricula were not developed as part of a comprehensive, implementation-oriented strategy. Any comprehensive model, therefore, should conceptually harmonise theory-driven measures that fulfil various purposes. For example, the measures that would be best used to help assess effectiveness of clinical training and provide feedback to improve their skills may well be different from assessments used to determine how patients perceive their providers’ abilities with respect to SDM. Nonetheless, the set of assessments should work together conceptually. Examples of this lack of harmonisation can be seen, for example, in how provider training for SDM has developed. Typically, SDM theories and assessments were not developed with teaching in mind. Therefore, existing models of instruction may not align with validated measures of SDM, making it difficult to tell if the instruction was successful.6 Measures of SDM, in turn, have mostly been developed to describe and define decision-making in clinical encounters, not as pedagogical tools. As a corollary, many models used to teach and evaluate communication skills (eg, The Four Habits),7 while they may …