What do you notice experienced clinicians do? Canada (n=142) The Netherlands (n=86) United Kingdom (n=172) United States (n=243) Paternalistic 43 (30.3) 39 (45.4) 38 (22.1) 73 (30.0) Shared decision making 58 (40.9) 21 (24.4) 80 (46.5) 114 (46.9) Informed decision making^ 24 (16.9) 5 (5.8) 19 (16.9) 26 (10.7) Semi-paternalistic 17 (12.0) 21 (24.4) 35 (20.4) 30 (12.4) Imagine that you are the clinician
in this situation, how would you react? Canada (n=142) The Netherlands (n=86) United Kingdom (n=172) United States (n=243) Paternalistic 17 (12.0) 13 (15.1) 16 (9.3) 27 (11.1) Shared decision making 94 (66.2) 49 (57.0) 106 (61.6) 173 (71.2) Informed decision making^ 26 (18.3) 8 (9.3) 28 (16.3) 28 (11.5) Semi-paternalistic 5 (3.5) 16 (18.6) 22 (12.8) 15 (6.2) A 53-year-old male presents to his primary care physician for an annual physical exam. The patient asks his provider about the need to screen for colorectal cancer. (n=645) What do you notice experienced
clinicians do? Canada (n=143) The Netherlands (n=86) United Kingdom (n=172) United States (n=244) Paternalistic 27 (18.9) 27 (31.4) 25 (14.5) 41 (16.8) Shared decision making^ 69 (48.3) 26 (30.2) 96 (55.8) 124 (50.8) Informed decision making 36 (25.2) 19 (22.1) 32 (18.6) 57 (23.4) Semi-paternalistic 11 (7.7) 14 (16.3) 19 (11.1) 22 (9.0) Imagine that you are the clinician
in this situation, how would you react? Canada (n=143) The Netherlands (n=86) United Kingdom (n=172) United States (n=244) Paternalistic 7 (4.9) 10 (11.6) 6 (3.5) 11 (4.5) Shared decision making^ 103 (72.0) 53 (61.6) 127 (73.8) 182 (74.6) Informed decision making 26 (18.2) 15 (17.4) 30 (17.4) 45 (18.4) Semi-paternalistic 7 (4.9) 8 (9.3) 9 (5.2) 6 (2.5) ^Appropriate answer
Supplemental File A - Checklist for Reporting Results of Internet E-Surveys (CHERRIES)
Item Category Checklist Item Explanation
Page number
Design Describe survey design
Describe target population, sample frame. Is the sample a convenience sample? (In “open” surveys this is most likely.)
4 IRB (Institutional Review Board) approval and informed consent process
IRB approval Mention whether the study has been approved by an IRB.
4,17
Informed consent Describe the informed consent process. Where were the participants told the length of time of the survey, which data were stored and where and for how long, who the investigator was, and the purpose of the
study?
17
Data protection If any personal information was collected or stored, describe what mechanisms were
used to protect unauthorized access.
7
Development and pre-testing
Development and testing
State how the survey was developed, including whether the usability and technical functionality of the electronic questionnaire had been tested before fielding the questionnaire.
4-6 Recruitment process and description of the sample having access to the questionnaire
Open survey versus closed survey
An “open survey” is a survey open for each visitor of a site, while a closed survey is only open to a sample which the investigator knows (password-protected survey).
Contact mode Indicate whether or not the initial contact with the potential participants was made on the Internet. (Investigators may also send out questionnaires by mail and allow for Web- based data entry.)
6-7
Advertising the survey
How/where was the survey announced or advertised? Some examples are offline media (newspapers), or online (mailing lists – If yes, which ones?) or banner ads (Where were these banner ads posted and what did they look like?). It is important to know the wording of the
announcement as it will heavily influence who chooses to participate. Ideally the survey announcement should be published as an appendix.
6-7
Survey
administration
Web/E-mail State the type of e-survey (eg, one posted on a Web site, or one sent out through e- mail). If it is an e-mail survey, were the responses entered manually into a database, or was there an automatic method for capturing responses?
7
Context Describe the Web site (for mailing list/newsgroup) in which the survey was posted. What is the Web site about, who is visiting it, what are visitors normally looking for? Discuss to what degree the content of the Web site could pre-select the sample or influence the results. For example, a survey about vaccination on a anti-immunization Web site will have different results from a Web survey conducted on a government Web site
7
Mandatory/voluntary Was it a mandatory survey to be filled in by every visitor who wanted to enter the Web site, or was it a voluntary survey?
4
Incentives Were any incentives offered (eg, monetary, prizes, or non-monetary incentives such as an offer to provide the survey results)?
7
Time/Date In what timeframe were the data collected?
Randomization of items or
questionnaires
To prevent biases items can be randomized or alternated.
6
Adaptive questioning Use adaptive questioning (certain items, or only conditionally displayed based on responses to other items) to reduce number and complexity of the questions.
5,6
Number of items What was the number of questionnaire items per page? The number of items is an important factor for the completion rate.
Protocol manuscript
Number of screens (pages)
Over how many pages was the
questionnaire distributed? The number of items is an important factor for the completion rate.
Protocol manuscript
Completeness check It is technically possible to do consistency or completeness checks before the questionnaire is submitted. Was this done, and if “yes”, how (usually JAVAScript)? An alternative is to check for completeness after the questionnaire has been submitted (and highlight mandatory items). If this has been done, it should be reported. All items should provide a non-response option such as “not applicable” or “rather not say”, and selection of one response option should be enforced.
7
Review step State whether respondents were able to review and change their answers (eg, through a Back button or a Review step which displays a summary of the responses and asks the respondents if they are correct).
7
Response rates Unique site visitor If you provide view rates or participation rates, you need to define how you determined a unique visitor. There are different techniques available, based on IP addresses or cookies or both.
7
View rate (Ratio unique site
visitors/unique survey visitors)
Requires counting unique site visitors (not page views!) divided by the number of unique visitors of the first page of the survey. It is not unusual to have view
Unable to be determined
rates of less than 0.1 % if the survey is voluntary. available data, addressed on page 9 Participation rate (Ratio unique survey page visitors/agreed to participate
Count the unique number of visitors who visit the first page of the survey (or the informed consents page, if present) divided by the number of people who filled in the first survey page (or agreed to participate). This can also be called “recruitment” rate. 9 Completion rate (Ratio agreed to participate/finished survey)
The number of people agreeing to participate (or submitting the first survey page) divided by the number of people submitting the last questionnaire page. This is only relevant if there is a separate “informed consent” page or if the survey goes over several pages. This is a measure for attrition. Note that “completion” can involve leaving questionnaire items blank. This is not a measure for how completely
questionnaires were filled in. (If you need a measure for this, use the word
“completeness rate”.)
9
Preventing multiple entries from the same individual
Cookies used Indicate whether cookies were used to assign a unique user identifier to each client computer. If so, mention the page on which the cookie was set and read, and how long the cookie was valid. Were duplicate entries avoided by preventing users access to the survey twice; or were duplicate database entries having the same user ID eliminated before analysis? In the latter case, which entries were kept for analysis (eg, the first entry or the most recent)?
7
IP check Indicate whether the IP address of the client computer was used to identify potential duplicate entries from the same user. If so, mention the period of time for which no two entries from the same IP address were allowed (eg, 24 hours). Were duplicate entries avoided by preventing users with the same IP address access to the survey twice; or were duplicate database entries having the same IP address within a given period of
Protocol manuscript
time eliminated before analysis? If the latter, which entries were kept for analysis (eg, the first entry or the most recent)?
Log file analysis Indicate whether other techniques to analyze the log file for identification of multiple entries were used. If so, please describe.
n/a
Registration In “closed” (non-open) surveys, users need to login first and it is easier to prevent duplicate entries from the same user. Describe how this was done. For example, was the survey never displayed a second time once the user had filled it in, or was the username stored together with the survey results and later eliminated? If the latter, which entries were kept for analysis (eg, the first entry or the most recent)?
n/a, this was an open survey Analysis Handling of incomplete questionnaires
Were only completed questionnaires analyzed? Were questionnaires which terminated early (where, for example, users did not go through all questionnaire pages) also analyzed?
7
Questionnaires submitted with an atypical timestamp
Some investigators may measure the time people needed to fill in a questionnaire and exclude questionnaires that were submitted too soon. Specify the timeframe that was used as a cut-off point, and describe how this point was determined.
7
Statistical correction Indicate whether any methods such as weighting of items or propensity scores have been used to adjust for the non- representative sample; if so, please describe the methods.
n/a
Bron:
Eysenbach, G. (2004). Improving the quality of web surveys: the checklist for reporting results of internet e‐surveys (cherries). Journal of medical Internet research, 6(3)e34
Supplemental File B - Copy of survey in English
Medical School Student Survey on Shared-Decision Making [English] NOTES:
• An * indicates skip logic, which will cause some participants to see a different version of the question for country-based clarification.
• Page break in document does not equate to page break in online survey. (Q1 Language Selection – English or French)
Q2 How do you think healthcare decisions should be made?
The patient should make the final decision about which treatment she/he would receive. The patient should make the final decision about which treatment she/he would receive after
seriously considering my opinion.
As the physician, I should share responsibility with the patient for making the final decision about the treatment she should receive.
As the physician, I should make the final decision about which treatment the patient should receive after seriously considering the patient’s opinion.
As the physician, I should make the final decision about which treatment the patient should receive.
Q3 Please indicate your age using the dropdown menu.
Response choices in drop-down range from 18 years to over 65 years. Q4 How do you self-identify? Please choose from the options below. Female
Male
Transgender
Other identity, please specify: ____________________ I prefer not to say
Q5 Please indicate where you currently are in your medical education (medical school) using the dropdown menu below.
Year 1 Year 2 Year 3 Year 4 Year 5 Year 6
Q6 In what country are you currently receiving your medical school training? United States of America
United Kingdom Canada
The Netherlands
Other, please specify: ____________________
Q7* Which group or groups do you most closely identify with? Please choose all that apply. American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander White or Caucasian
Other: ____________________ I prefer not to say
Q8* Are you Spanish, Hispanic, or Latino? Yes
No
I prefer not to say
Q11 What medical school do you attend? Please provide the full institution name, no abbreviations.
Q12 Please indicate how much you agree or disagree with the following statements. Strongly
Agree Agree Disagree
Strongly Disagree Shared decision making can
only be done with patients who are sufficiently educated and confident to discuss treatment or
screening options with their clinician.
Doing shared decision making is unrealistic because it takes too
much time.
Doing shared decision making is
low on my priority list.
Physician payment should be based on how well they do
shared decision making.
Having resources which summarize the risks and benefits of clinical decisions would be helpful (e.g. patient
decision aid).
Patients should trust clinicians to make all decisions on their
behalf.
Q13 Read the following scenario. Please indicate: (A) what you notice experienced clinicians do (e.g., attending physicians, residents, interns), and (B) which decision style you would adopt if you were in this situation. There are no right or wrong answers. Assume consent is obtained for each patient.
Q14 A 45-year-old female presents to the Emergency Department. She requires an urgent emergency surgical intervention but is capable of giving consent.
Q15* A. What do you notice experienced clinicians do (e.g., attending physicians, residents, interns)?
Experienced clinicians use evidence-based information to decide on the best course of action for the patient and inform the patient of their decision.
Experienced clinicians share evidence-based information with the patient, and elicit the patient's preferences, so the clinician and patient can make an informed decision together. Experienced clinicians share evidence-based information with the patient and allow the
patient to make the decision on their own.
Experienced clinicians share evidence-based information with the patient and choose the best course of action for the patient.
Q18 B. Imagine that you are the clinician in this situation, how would you react?
I would use evidence-based information to decide on the best course of action for the patient and inform the patient of my decision.
I would share evidence-based information with the patient, and elicit the patient's preferences, so the patient and I can make an informed decision together.
I would share evidence-based information with the patient and allow the patient to make the decision on their own.
I would share evidence-based information with the patient and choose the best course of action for the patient.
Q19 Read the following scenario. Please indicate: (A) what you notice experienced clinicians do (e.g., attending physicians, residents, interns), and (B) which decision style you would adopt if you were in this situation. There are no right or wrong answers. Assume consent is obtained for each patient.
Q20 A 53-year-old male presents to his primary care physician for an annual physical exam. The patient asks his provider about the need to screen for colorectal cancer.
Q21* A. What do you notice experienced clinicians do (e.g., attending physicians, residents, interns)?
Experienced clinicians use evidence-based information to decide on the best course of action for the patient and inform the patient of their decision.
Experienced clinicians share evidence-based information with the patient, and elicit the patient's preferences, so the clinician and patient can make an informed decision together. Experienced clinicians share evidence-based information with the patient and allow the
patient to make the decision on their own.
Experienced clinicians share evidence-based information with the patient and choose the best course of action for the patient.
Q24 B. Imagine that you are the clinician in this situation, how would you react?
Experienced clinicians use evidence-based information to decide on the best course of action for the patient and inform the patient of their decision.
Experienced clinicians share evidence-based information with the patient, and elicit the patient's preferences, so the clinician and patient can make an informed decision together. Experienced clinicians share evidence-based information with the patient and allow the
patient to make the decision on their own.
Experienced clinicians share evidence-based information with the patient and choose the best course of action for the patient.
Q25 A 40-year-old male with a family history of Cancer A visits his physician to discuss undergoing a scheduled screening for Cancer A. What is considered the most effective way of communicating how screening changes his risk of mortality from Cancer A?
Screening results in a 50% reduction in mortality.
Screening reduces mortality from 6 out of 10,000 people to 3 out of 10,000 people. Screening reduces mortality by 0.02%.
Screening dramatically decreases his mortality from Cancer A.
Q26 Please indicate whether you feel each of the following statements is TRUE or FALSE.
True False
Shared decision making is a process in which clinicians and patients work together, sharing information about options and preferred outcomes, in order to reach a mutual agreement on the
best course of action.
Shared decision making causes patients to feel uncertain about
their decisions.
Shared decision making increases patient decision regret. Shared decision making results in fewer patients choosing major
surgery.
Q27 Please indicate whether you feel each of the following statements is TRUE or FALSE.
True False
When communicating information about risks, it is best to use relative risk (e.g., there is double the risk of developing thrombosis
when using oral contraceptives).
Evidence shows that involving patients in making important
healthcare decisions increases knowledge. To promote shared decision making, the clinician will indicate that
Q28 Please indicate whether you feel each of the following statements is TRUE or FALSE.
True False
To promote shared decision making, the clinician will give information about the pros and cons of options that are considered
reasonable (including taking 'no action')
To promote shared decision making, the clinician will support the
patient in becoming informed and comparing options. There is no need for the clinician to check the patient's
understanding.
In the shared decision making process, it is necessary to elicit the
patient's preferences.
Q29 Please indicate whether you feel each of the following statements is TRUE or FALSE.
True False
Whenever possible, the clinician should integrate the patient's
preferences in deciding what to do next. Most people will understand natural frequency (e.g., 1 in every 100
people) better than a percentage. A majority of patients do not want to engage in shared decision
making with their clinician.
Even if the patient does not wish to be involved in the decision making process, it is the clinician's role to encourage the patient to
make a decision.
Q30 Had you heard of shared decision making before completing this survey? Yes
No
Q31 Have you received training in shared decision making?
Yes No
I have received formal theoretical shared decision making
training (e.g., didactic learning). I have received formal practical shared decision making
Q32 Roughly how many hours of training (combined theoretical and practical) have you received in shared decision making?
0 to 1 hours
Between 1 to 2 hours Between 2 to 5 hours Greater than 5 hours OR
Automatically directed to Q33 if the answer to both statements in Q31 were ‘No’. OR
Q33 Please indicate how much you agree or disagree with the following statement. Strongly
Disagree Disagree Agree
Strongly Agree I would like to know more about
how to do shared decision with patients.
Q34 In a clinical encounter, how do you think engaging in shared decision making would affect the length of the visit?
Decrease the overall length of the visit.
The length of the visit would remain the same. Increase the overall length of the visit.
Q35 You selected "Decrease the overall length of the visit." How much shorter would the clinical visit be when engaging in shared decision making?
About 5 minutes shorter, or more About 2 minutes shorter
About 1 minute shorter OR
Q36 You selected "Increase the overall length of the visit." How much longer would the clinical visit be when engaging in shared decision making?
About 1 minute longer About 2 minutes longer
About 5 minutes longer, or more OR
Automatically directed to Q37 if answer to statement in Q34 was ‘The length of the visit would remain the same.’
Q37 How do you think healthcare decisions should be made?
The patient should make the final decision about which treatment she would receive. The patient should make the final decision about which treatment she would receive after