FOCUSED ISSUE OF THIS MONTH pISSN 1975-8456 eISSN 2093-5951

J Korean Med Assoc 2025 September; 68(9):559 [Link]

Patient-centered care and shared decision-making:

core concepts and implementation strategies: a
narrative review
Min Ji Kim, PhD, Sang-Ho Yoo, MD, PhD
Department of Medical Humanities and Ethics, Hanyang University College of Medicine, Seoul, Korea

Purpose: Shared decision-making (SDM) in healthcare is defined as a collaborative communication process among health-
care professionals, patients, and their primary caregivers to make decisions that reflect patients’ preferences and values. This is
achieved by comparing multiple medically acceptable options based on medical evidence and clinical judgment. This review
aims to examine the core concept of SDM and explore strategies for its implementation to advance patient-centered care in
clinical practice.
Current Concepts: SDM involves defining problems, presenting available options, explaining these options, identifying
patients’ values and preferences, providing patient decision aids, and ultimately making decisions. To facilitate SDM, several
strategies can be applied based on the conceptual model. These include training healthcare professionals, developing patient
decision aids, and encouraging patients to participate actively in health-related decisions.
Discussion and Conclusion: To successfully implement SDM in the Korean healthcare system, a shift from the prevailing
paradigm is required, with a long-term perspective. To advance SDM, it is necessary to (1) develop an evidence-based Korean
SDM model and training programs for healthcare professionals, (2) identify the most effective content and formats of patient
decision aids for supporting patients with decisional needs, and (3) establish methods for institutionalizing SDM within clinical
workflows to enable policy-level adoption.

Key Words: Decision making, shared; Patient-centered care; Patient participation; Personal autonomy; Patient decision
aid

Introduction and values. At the center of this shift is patient-centered

care, which prioritizes respect for patients’ values, prefer-
1. Background ences, and needs while incorporating them into clinical
Modern medicine is transitioning from the sole treat- decision-making [1]. In its 2001 report, ‘Crossing the quali-
ment of disease to an emphasis on patients’ quality of life ty chasm: A new health system for the 21st century,’ the In-
stitute of Medicine identified care that places patient val-
ues at the core of clinical decisions as the foundation of
Received: July 8, 2025 Accepted: August 5, 2025 patient-centered care and recommended it as a guiding
Corresponding author: Sang-Ho Yoo
E-mail: karmaboy@[Link] principle for 21st-century healthcare [1].
For patient-centeredness to be realized in clinical prac-
© Korean Medical Association
tice, patients must act as active participants rather than
This is an Open Access article distributed under the terms of the Creative Commons
Attribution Non-Commercial License ([Link] passive recipients in the medical decision-making process.
by-nc/4.0) which permits unrestricted non-commercial use, distribution, and
reproduction in any medium, provided the original work is properly cited. Shared decision-making (SDM) is a communication meth-

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od that embodies this principle. SDM is a collaborative due to short consultation times and physician-centered
process in which healthcare professionals (HCPs) and pa- communication structures [9]. These limitations, however,
tients engage in mutual discussion based on respect and underscore the urgency of adopting SDM. By delivering es-
trust, review different medical options—such as treatments sential information efficiently and fostering patient en-
or examinations—and jointly reach an optimal decision gagement within limited time frames, SDM provides a
aligned with the patient’s values and preferences [2]. This practical means to simultaneously improve both the quali-
model has gained recognition as a decision-making ap- ty and efficiency of care.
proach that ensures patient autonomy while integrating
the expertise and clinical evidence provided by HCPs. 2. Objectives
The importance and effectiveness of SDM are particular- Recently, a shift toward patient-centered care has been
ly highlighted in preference-sensitive conditions, where explored at the policy level by both the Korean government
multiple medically valid options exist and the decision de- and the medical community [10], with the emergence of
pends largely on patient values. Examples include cancer SDM recognized as a key strategy. Accordingly, this review
screening, preventive medication therapy, and elective aims to summarize the concept, components, and clinical
surgical procedures, where decisions extend beyond pure- applications of SDM; examine various conceptual models
ly medical considerations to reflect the broader context of and implementation strategies; and introduce patient de-
patients’ lives [3]. The US Preventive Services Task Force cision aids (PtDAs) and training approaches for HCPs that
has consistently emphasized the need for SDM in such encourage the practice of SDM. Furthermore, we compare
preference-sensitive settings [4]. major SDM evaluation tools and propose institutional
The justification for SDM is rooted not only in ethical im- foundations and future directions for realizing SDM in the
peratives but also in empirical evidence. Numerous studies Korean healthcare system. Through this effort, we seek to
have shown that SDM improves communication quality establish both theoretical and practical foundations that
between patients and HCPs and enhances patients’ clinical enable clinicians, policymakers, and researchers to better
experiences. Patients in several countries, including Korea, understand SDM and apply it effectively in practice and
reported significantly higher satisfaction with communica- policy.
tion when SDM was practiced, and some studies demon-
strated increased satisfaction with treatment decisions Concept and Application of Shared Decision-Making
[5,6]. A large-scale panel study in the United States further SDM in healthcare is a collaborative communication
revealed reduced annual healthcare expenditures among process among HCPs, patients, and their primary caregiv-
patients who actively engaged in SDM [7]. These findings ers, designed to ensure that decisions reflect patients’ pref-
suggest that SDM can improve both healthcare effective- erences and values by comparing multiple medically valid
ness and cost efficiency. Additionally, in a simulation study options based on evidence and clinical judgment. In this
involving delayed emergency room diagnoses, 41% of pa- process, patients are supported in evaluating the benefits
tients considered legal action when SDM was absent, com- and risks of each option using the best available evidence,
pared with only 11% when patients had adequate SDM ex- while also clarifying their values and preferences and re-
periences [8]. Such evidence supports the view that SDM is flecting on their choices [11]. SDM relies on mutual respect
more than a tool for patient participation; it is a key strate- and the exchange of information between patients and
gy for improving care quality, patient safety, and the physi- HCPs, integrating medical expertise with value-based deci-
cian–patient relationship. sions. Clinicians present treatment options grounded in
Despite this global trend, the Korean healthcare system scientific evidence and fully explain the benefits, risks, and
continues to face challenges in implementing SDM, largely uncertainties of each option, thereby assisting patients in

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 Kim MJ · Yoo SH · Patient-centered care and shared decision-making

deliberating within the context of their personal lives. Pa- step.

tients are encouraged to participate actively in this process, In summary, SDM operationalizes patient-centered care
often with the aid of tools such as PtDAs, when necessary. through a sequence of information exchange, joint deliber-
In this regard, SDM represents a more advanced concept ation, and agreement on a decision. The collaborative rela-
than informed consent. Whereas informed consent tradi- tionship and mutual respect between patients and HCPs
tionally involves an HCP providing information followed remain the foundation of SDM throughout this process.
by passive patient consent [12], SDM emphasizes the shar-
ing of information and joint deliberation, resulting in mu- Conceptual Models of Shared
tual agreement [13]. This distinction underscores the add- Decision-Making
ed value of SDM as a more participatory and balanced
decision-making approach. To apply SDM effectively in clinical practice, several con-
SDM is particularly critical in preference-sensitive situa- ceptual models have been developed to systematize its es-
tions, where two or more medically acceptable treatment sential components and procedures. These models de-
options exist but no single choice is clearly superior, or scribe the SDM process step by step, illustrating how it can
where the best option depends on the patient’s personal be practically implemented in clinical settings. They serve
values. Such situations frequently involve medical uncer- as practical guides for both HCPs and patients unfamiliar
tainty, and because patients weigh risks differently and with SDM, enabling them to understand and apply the de-
place varying emphasis on quality of life, individualized cision-making process. In addition to providing procedural
decisions through SDM are preferable to unilateral clinical clarity, these models offer a theoretical foundation for de-
judgments [14]. Representative examples include selecting signing implementation strategies and creating supportive
a treatment strategy for coronary artery disease [15], decid- environments to institutionalize SDM in healthcare sys-
ing on surgical options for early-stage breast cancer or re- tems.
constructive surgery [16], and determining whether to un- Representative models include the integrative model,
dergo surgery for arthritis [17]. Although these decisions the Three-talk model, the Four step model, and the Six step
are supported by medical evidence, the absence of one model. While all adhere to the fundamental principles of
clearly superior option means the final choice must align SDM, each has distinct characteristics regarding emphasis
with the patient’s life context, values, and preferences. and structure. These models can be flexibly applied de-
Thus, in such cases, SDM is not optional but essential for pending on the clinical context and provide a conceptual
ensuring high-quality care. The components of SDM are framework for practicing SDM in a consistent manner.
generally structured as follows [18]:
• Recognizing and clarifying the problem that requires a 1. Integrative model (2006)
decision To clarify the definition of SDM, Makoul and Clayman
• Presenting evidence-based options and providing in- [19] conducted a systematic review of 161 studies and, in
formation through an HCP 2006, proposed an integrative model synthesizing prior
• Explaining the advantages, disadvantages, and uncer- findings. They extracted nine essential elements, four ideal
tainties of each option elements, and 10 general qualities of SDM from various
• Clarifying the patient’s values and preferences models. The nine essential elements were (1) defining/ex-
• Providing time for deliberation, support, and additional plaining problems, (2) presenting options, (3) discussing
information for decision-making pros/cons, (4) clarifying patient values/preferences, (5)
• Arriving at a decision based on mutual agreement be- discussing patient ability/self-efficacy, (6) recommending
tween the HCP and the patient and planning the next based on the doctor’s expertise, (7) checking understand-

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ing, (8) making or deferring a decision explicitly, and (9) or multiple conditions, establishing three tiers of patient
arranging follow-up [19]. The integrative model is signifi- care goals: fundamental, functional, and symptom- or dis-
cant for its comprehensive unification of previously scat- ease-specific goals [24]. In the most recent 2021 revision,
tered SDM elements and has served as a benchmark for greater emphasis was placed on team talk compared to
subsequent models [20]. It also prompted the critical ques- previous versions, particularly to restore the autonomy of
tion: ‘Is the developed SDM model appropriate for each vulnerable patient populations [25]. Moreover, SDM was
healthcare system?’, stimulating the development of more framed not merely as a decision-making skill but as an in-
practical and context-specific models. tertwined process of communication and collaboration
[26], further characterized as an ‘existential journey’ that
2. Three-talk model (2012, 2017, 2020, 2021) restores the patient’s autonomy [27]. The most recent ver-
One of the most widely recognized SDM models is the sion highlights the evolution of the Three-talk model into
3-talk model proposed by Elwyn et al. [21]. Initially intro- one that prioritizes building relationships and promoting
duced in 2012, this model classified the SDM process into collaboration between patients and HCPs.
three stages: Choice talk, Option talk, and Decision talk. In
the Choice talk, patients are first informed that a medical 3. Four step model (2015)
decision must be made and that two or more options are Charles et al. [28], who first academically established the
available. This step helps patients recognize from the out- concept of SDM in 1997, stressed that proper implementa-
set that there are multiple possibilities and that their pref- tion requires more than information exchange; it must also
erences will be considered. In the Option talk, HCPs pro- incorporate patients’ preferences and values during medi-
vide detailed information on each option, including its cal encounters. A review of the literature on the definition
advantages and disadvantages, which patients then delib- of SDM further demonstrated that more than half of the
erate upon. At this stage, PtDAs may be provided to sup- studies identified the inclusion of patient preferences as a
port patients’ understanding. Finally, in the Decision talk, central element [19,29]. In this context, Stiggelbout et al.
patients and HCPs confirm what matters most to the pa- [30] introduced the Four step model in 2015, which ex-
tient and either make a choice based on patient values and panded the Three-talk model by explicitly including dia-
preferences or defer the decision. The three-talk model has logue about patient preferences. In the first step, HCPs in-
undergone several revisions. In 2017, the first step was re- form patients that a decision of significance must be made.
named from Choice talk to Team talk, emphasizing sup- Second, they explain the available options, including the
portive exploration with patients. benefits and risks of each. The third step—newly added
In this revised framework, patients and HCPs are con- compared with the Three-talk model—involves eliciting
ceptualized as teams working together to determine the patients’ preferences and providing sufficient time for de-
best option. Patients are granted adequate time for deliber- liberation. In the final step, patients and HCPs confirm the
ation, and HCPs are advised to ‘listen actively’ throughout role that patients wish to take in decision-making, after
the entire process [22]. Sample guiding phrases were also which a collaborative decision is reached or deferred with
suggested to facilitate patient-centered communication a follow-up plan agreed upon. The Four step model reflects
during each step [23]. For instance, “Let’s work together as the essential spirit of SDM because it directly incorporates
a team to find the best solution for you” corresponds to and emphasizes patient values and preferences in the de-
Team talk, “Let’s weigh our options to see which is best” cision-making process.
applies to Option talk, and “What factors are most import-
ant to you?” is used for Decision talk. In 2020, a Goal-based 4. Six step model (2024)
three-talk model was proposed for patients with complex In Germany, where SDM research has been particularly

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 Kim MJ · Yoo SH · Patient-centered care and shared decision-making

active, a large-scale implementation initiative called Share SDM training programs in Germany and is being adopted
to Care was undertaken to translate the theory of SDM into in other countries as well (Table 1) [19,21,30,32].
clinical practice [31]. From this initiative, the Six step mod-
el was developed and formally published in 2024. This Implementation Frameworks and
model streamlines the nine essential elements of the Inte- Strategies
grative model [19] by removing unnecessary or overly
complex components, thereby making it easier for clini- To effectively implement theoretical models in clinical
cians to learn and apply in practice. The Six step model practice, well-structured implementation frameworks and
consists of: (1) defining the goal of the consultation: pa- strategies are essential. SDM cannot be established merely
tients and HCPs agree on the objective to be achieved; (2) by teaching communication skills to individual HCPs; it
explaining the necessity of patient participation: patients also requires institutional foundations that ensure SDM
are informed about the importance of their engagement in functions sustainably across healthcare organizations. Im-
decision-making; (3) explaining options and their pros/ plementation frameworks and strategies therefore encom-
cons: several medically valid options, including ‘doing pass the structural measures and environmental develop-
nothing,’ are explained objectively with associated benefits ments necessary for embedding SDM into daily practice.
and risks; (4) exploring patient preferences and needs: pa- This includes leadership support, redesign of clinical pro-
tients articulate their concerns, priorities, and expectations cesses, establishment of patient education and support
for each option; (5) making shared or deferred decisions: a systems, integration with information technology, and de-
joint decision is made after adequate discussion, or the de- velopment of evaluation and compensation systems. As
cision is postponed by mutual agreement if more time is evidence of SDM’s clinical benefits has accumulated, sev-
required; (6) putting decisions into practice: the chosen eral countries have pursued strategic implementation proj-
decision is implemented, and a follow-up schedule is es- ects to integrate SDM into healthcare systems [33]. Among
tablished [32]. This Six step model is notable for its high these, Share to Care (Kiel, Germany) [31] and SDM:HOSP
practicality, simplicity, and adaptability, making it particu- (Vejle, Denmark) [34] stand out as successful hospital-wide
larly useful for HCPs. It has already been incorporated into SDM implementation frameworks. Both provide valuable

Table 1. Characteristics of each shared decision-making model

Integrative model 3-Talk model 4-Step model 6-Step model
Developer Makoul and Clayman [19] Elwyn et al. [21] Stiggelbout et al. [30] Clayman et al. [32]
Year 2006 2012 2015 2024
Origin Systematic review and meta-analysis - Modified from the Three-talk Modified from the Integrative
of 161 studies model model
Core elements • Defining/explaining problems • Team talk • Informing the patient that the • Defining the goal of consultation
• Presenting options • Option talk decision is to be made and the • E xplaining the need for
• Discussing pros and cons • Decision talk patient’s opinion is important participation
• Patient values/preferences • E xplaining the options and the • E xplaining the pros and cons of
• Discussing patient ability/self- pros and cons of each option each option, including doing
efficacy •D  iscussing patient preferences nothing
• Recommending the doctor’s and supporting deliberation • E xploring preferences and needs
knowledge •D  iscussing the patient’s wish to •M  aking a shared decision or
• Clarifying understanding make the decision, deferring a decision
• Making or deferring a decision • Putting the decision into practice
explicitly
• Arranging follow-up
-, not applicable.

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insights for the Korean healthcare system. Their core con- Share to Care framework. Each component was validated
tent and structural features are described below. in randomized comparative studies, confirming its effec-
tiveness as a robust SDM implementation strategy.
1. Share to Care program
The German National Competency Center for Shared 2. SDM:HOSP program
Decision Making developed an implementation strategy The Danish Center for Shared Decision Making designed
with four components to systematically apply SDM at the the SDM:HOSP program as a hospital-centered framework
hospital level: physician training, HCP integration, patient for embedding SDM using a quality improvement method-
activation, and the development of evidence-based PtDAs ology [38]. This approach reorganized hospital systems
[31,32]. with SDM as a central focus.
First, physician training: All physicians were required to Its core components include: (1) Training leaders: De-
complete online training to familiarize themselves with the partmental leaders, including physicians, nurses, and psy-
SDM concept and the Six step model. Physicians also prac- chologists, underwent training in SDM principles and in
ticed SDM with real patients using video recordings and their role as facilitators of SDM culture within their teams
received structured feedback. Training outcomes were [39]; (2) Training clinicians as teachers: Selected clinicians
evaluated using a self-developed tool that provided quanti- attended a two-day intensive workshop covering SDM
tative feedback on improvements in SDM skills [35]. Sec- knowledge, simulation exercises with feedback, and PtDA
ond, HCP integration: In addition to physicians, other use. These clinicians then served as in-house SDM teach-
HCPs such as nurses were trained as decision counselors ers, disseminating skills and principles to colleagues [34];
or decision coaches. Their responsibilities included pro- (3) Developing high-quality PtDAs: Recognizing that PtDA
viding patients with preparatory information before con- quality is critical for SDM success, the Danish team created
sultations, coaching them on PtDA use, and facilitating ac- their own standardized template called DESITION HELP-
tive patient participation in discussions with physicians ER™. This tool can be adapted to diverse clinical situations
[36]. Through this interprofessional collaboration, HCPs and was developed in line with the International Patient
acted as bridges between patients and physicians, substan- Decision Aids Standards (IPDAS) [40–42]. Its design in-
tially improving patient activation and decisional support cludes fixed qualifying criteria that must always be met,
[37]. Third, patient activation: The program emphasized along with flexible essential and enhancing criteria; (4)
creating an environment that encouraged patients to en- Setting implementation processes: To systematically em-
gage actively in medical decisions. Educational materials bed SDM into routine practice, an implementation start-
such as informational leaflets were placed in waiting areas er-kit was introduced. The kit outlined a one-year roadmap
with messages like “Engage in your own health-related de- with detailed milestones, such as tasks for the first month,
cisions.” Clinicians were trained to invite patients to ex- scheduled meetings for the third month, and outcome as-
press their questions and preferences at the beginning of sessments for the 6th month. It also provided templates for
consultations [32]. Fourth, PtDA development: Over 80 ev- meeting agendas, educational materials, and methods for
idence-based PtDAs were created in digital formats, using sharing progress across departments.
graphs, tables, and educational videos featuring both ex- Through these structured measures, SDM:HOSP suc-
perts and patients. These PtDAs were accessible via an on- cessfully fostered an SDM culture at the hospital level, en-
line portal, enabling patients to learn about their condi- suring both sustainability and system-wide integration
tions and treatment options at any time [37]. Together, [34].
these four pillars—physician training, HCP integration, pa-
tient activation, and PtDA development—constitute the

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 Kim MJ · Yoo SH · Patient-centered care and shared decision-making

Measures to Promote Shared criteria [44]. Additionally, when reporting PtDA research

Decision-Making findings, the Standards for universal reporting of patient

decision aid evaluations (SUNDAE) guidelines are recom-
1. Patient decision aids mended [45].
PtDAs are one of the most prominent tools for promoting Internationally, well-known examples of PtDAs include
SDM, as they encourage patients to deliberate and actively the Ottawa Personal Decision Guide, developed by the Ot-
participate in decision-making [3]. They are structured de- tawa Hospital Research Institute in Canada, and Decision
cision-support resources designed to help patients make Helper, developed by the Danish Center for Shared Deci-
informed choices in situations involving multiple medical sion Making. The Ottawa Personal Decision Guide is a ge-
options, such as treatments, diagnostic tests, or preventive neric PtDA that supports patients in clarifying their choic-
measures. PtDAs provide balanced, evidence-based infor- es, identifying needs, and deliberating across a range of
mation and clearly present the potential outcomes, risks, clinical contexts. It uses a checklist format with value clari-
harms, and uncertainties of each option. This information fication items and structures for option comparison [46]. In
is delivered in an accessible format, using words, numbers, contrast, the DESITION HELPER is a disease-specific
or diagrams, to enhance comprehension and reduce deci- PtDA, tailored to particular clinical conditions. It provides
sion-making bias. Unlike general educational materials, patients with condition-relevant information and helps
PtDAs play a unique role in clarifying patients’ values by them reflect on their values and preferences [41]. In Korea,
encouraging them to reflect on what matters most in their systematic and standardized development of PtDAs has
lives. This process reinforces the two core components of not yet been fully established. Nonetheless, adoption has
SDM—value-based deliberation and active patient partici- gradually expanded in specific clinical contexts, including
pation. PtDAs can be used before, during, or after a consul- end-stage renal disease, selected cancers, fertility preserva-
tation and are available in diverse formats, including pam- tion, and periodontal disease.
phlets, booklets, checklists, videos, web pages, and mobile The effectiveness of PtDAs has been consistently demon-
applications. strated in systematic reviews. A 2024 Cochrane review ana-
To ensure their effectiveness, PtDAs must meet interna- lyzing more than 100 randomized controlled trials reported
tionally recognized requirements. The IPDAS Collabora- that patients who used PtDAs showed improved knowl-
tion, launched in 2003, developed global standards for the edge, greater alignment between chosen options and their
design, evaluation, and reporting of PtDAs [43]. These personal values, and higher levels of participation in medi-
standards classify requirements into three groups. First, cal decision-making [40]. PtDAs also significantly reduced
qualifying criteria are mandatory elements that define a decision conflict caused by insufficient information, and
PtDA as a decision-support tool, including the presenta- tools such as icon arrays effectively improved risk percep-
tion of multiple options and provision of balanced infor- tion accuracy [40]. However, consistent evidence demon-
mation. Second, essential criteria ensure neutrality and strating that PtDAs improve long-term health outcomes or
credibility, evaluating whether the PtDA presents each op- quality of life remains limited [40]. Future research should
tion without bias and whether it fairly outlines benefits and therefore focus on developing and rigorously evaluating
risks. Third, enhancing criteria further improve the com- PtDAs tailored to specific cultural and institutional con-
pleteness of PtDAs by addressing the appropriateness of texts.
visual materials, the involvement of patients in develop- Given the limited consultation times in clinical practice,
ment, the conduct of usability testing, and the use of up-to- PtDAs provide a practical means of supporting patients in
date evidence [42]. As of its fifth edition in 2025, IPDAS making decisions that reflect their values and preferences.
provides 39 specific items distributed across these three They should be regarded as a central strategy for advancing

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patient-centered care and for embedding SDM into routine clinicians from each department as key trainees, who then
clinical practice. The systematic development and dissem- act as teachers and spread SDM principles throughout the
ination of standardized PtDAs appropriate for the Korean hospital [34].
healthcare system must be considered a priority for estab- These training initiatives extend beyond technical skills,
lishing SDM. covering content that ranges from the ethical and philo-
sophical foundations of SDM to practical language and sit-
2. Education and Training uational response strategies useful in clinical settings.
In addition to PtDAs, education and training for HCPs are Simulation-based training, video feedback, and post-
core strategies for disseminating SDM. To perform SDM ef- implementation evaluation are widely used to reinforce
fectively, HCPs must acquire interactive communication SDM application after formal instruction [51,52]. In Korea,
skills that enable them to explain different options clearly some academic societies, such as the Korean Society of
and in a structured way so that patients can understand, ex- Nephrology, have hosted SDM workshops. However, sys-
plore their values and preferences, and strengthen self-de- tematic incorporation of SDM training into regular medical
termination. In SDM, the ability to communicate risk is es- curricula and continuing education remains limited. Mov-
pecially critical, as patients must often weigh uncertain ing forward, SDM education must be integrated into the
prognoses and risk factors for each option [47]. HCPs should curricula of medical and nursing colleges and expanded
be able to use visual aids or analogies to convey numerical into standardized training during residency and profes-
data—such as absolute risk, relative risk, or incidence sional development. This would ensure that HCPs gain the
rates—without causing misunderstanding, since such data skills to make decisions that reflect not only clinical judg-
directly influence patients’ value-based judgments. There- ment but also patient values and preferences during medi-
fore, SDM education must focus not only on providing infor- cal encounters.
mation but also on cultivating communication skills that
support risk perception and value clarification. Evaluation Tools of Shared
Many countries have developed and disseminated train- Decision-Making
ing programs to strengthen SDM competencies. For in-
stance, the Agency for Healthcare Research and Quality To establish and disseminate SDM in clinical practice, it
has formalized the communication process into the is essential to evaluate its performance both quantitatively
SHARE (Seek participation, Help compare, Assess values, and qualitatively [53]. Over the past several decades, nu-
Reach decision, Evaluate decision) Approach [48], comple- merous evaluation tools have been developed, which can
mented by web-based education and clinical guidelines be categorized by the evaluator, timing, and purpose of
[49]. Countries such as Canada, Australia, and the Nether- evaluation. Tools can be classified according to the evalua-
lands have integrated SDM concepts and practical training tor—patient, clinician, or observer—enabling complemen-
into the core curricula of medical schools and health- tary perspectives: patient-reported experiences, clinician
care-related departments [50], in addition to providing self-assessment, and objective coded observations. Evalu-
continuing professional development programs for HCPs. ations may also be categorized as antecedent (measuring
Germany and Denmark provide leading examples, having patient readiness or attitudes before SDM), process (mea-
institutionalized SDM at the hospital level through phased suring the SDM process itself), or outcome (assessing re-
education strategies. The Share to Care program combines sults such as knowledge level, satisfaction, or reduced de-
online theoretical education with repeated training and cisional conflict) [53].
feedback using real patient cases for all physicians in a The first evaluation tool developed was the Observing
hospital [32]. The SDM:HOSP program selects dedicated patient involvement in decision making (OPTION) scale,

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 Kim MJ · Yoo SH · Patient-centered care and shared decision-making

designed by Elwyn et al. [54] in 2003 to allow observers to of patient, clinician, and observer. It includes 11 partici-
assess patient-clinician communication. The original ver- pant items [59] and 15 observer items [60], scored on a
sion (OPTION-12) measured 12 behaviors, such as encour- 5-point Likert scale. This tool is particularly useful for re-
aging patient participation and explaining available op- search and training evaluations because it allows compar-
tions. A simplified version, OPTION-5, was introduced in ative analysis across perspectives, although its complexity
2013 to improve usability [55]. Another adaptation, OP- limits routine clinical use.
TION-Dyadic (2010), uses mirrored self-report question- CollaboRATE, developed by Elwyn et al. [61] in 2013, is a
naires for both patients and clinicians, enabling compari- short, patient-reported tool consisting of 3 questions on
son of their perceptions of the same consultation [56]. whether the HCP adequately considered the patient’s
The Shared Decision-Making Questionnaire (SDM-Q-9), views. Using a 0–4-point scale, it requires less than one
developed in Germany in 2006, is a nine-item patient minute to complete, making it highly practical for immedi-
self-report instrument assessing the stages of SDM [57]. ate surveys and large-scale assessments. However, it has
Patients complete it immediately after consultation to eval- limitations in terms of providing detailed feedback. Cur-
uate physician performance. The corresponding doctor rently, several language versions are available.
version, the SDM-Q-Doc, contains the same items with Additional tools include the decisional conflict scale [62],
wording adjusted to reflect the doctor perspective [58]. To- which measures the extent of patient uncertainty in making
gether, these tools allow for direct comparison of patient decisions, and the decision regret scale [63], which assesses
and clinician views, making them valuable for training and satisfaction and regret after decisions. Communication skill
feedback. assessment instruments are also used as supplementary
Another comprehensive tool is Multifocal approach to measures. The above tools are summarized in Table 2 [54–
sharing in SDM (MAPPIN’SDM), developed in Germany in 59,61–63].
2012. It evaluates SDM performance from the perspectives The choice of evaluation tool depends on both the pur-

Table 2. Shared decision-making evaluation tools

Year of
Name Developer Evaluator Key features
publication
OPTION-12 Elwyn et al. [54] 2003 Observer Evaluates patient-healthcare professional
communication. Measures 12 key SDM behaviors.
OPTION-5 Elwyn et al. [55] 2013 Observer A summarized version of OPTION-12, designed for
improved practicality.
OPTION-Dyadic Melbourne et al. [56] 2010 Patient and healthcare Patients and healthcare professionals self-report on
professional the same items, allowing for a comparison of their
perceptions.
SDM-Q-9 Kriston et al. [57] 2010 Patient A nine-item questionnaire for patients to
subjectively evaluate SDM.
SDM-Q-Doc Scholl et al. [58] 2012 Physician The same item structure as the SDM-Q-9, but
worded for physicians.
MAPPIN’SDM Kasper et al. [59] 2012 Patient, healthcare Comprehensively measure SDM from three
professional, and observer perspectives.
CollaboRATE Elwyn et al. [61] 2013 Patient Three items–a practical and straightforward tool
Decisional conflict scale O’Connor [62] 1995 Individuals Measures personal perceptions of uncertainty in
choosing options
Decision regret scale Brehaut et al. [63] 2003 Individuals A 5-item scale to measure regret after health-
related decisions
OPTION, observing patient involvement in decision making; SDM, shared decision-making; SDM-Q, SDM Questionnaire; SDM-Q-Doc, SDM
Questionnaire—doctor version; MAPPIN’SDM, multifocal approach to sharing in shared decision-making.

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pose and the clinical context. For instance, short and sim- often struggle to implement it due to entrenched commu-
ple self-report surveys such as the SDM-Q-9 or Collabo- nication patterns and limited consultation times. Identified
RATE are well suited for gathering rapid feedback on barriers include a lack of understanding of SDM among
patient experiences in clinical practice. For more precise or clinicians, insufficient communication skills, concerns
standardized evaluation—such as assessing the effective- about appearing indecisive, and perceptions that patients
ness of training programs or conducting institutional ac- prefer not to participate in decision-making. On the patient
creditation—observation-based tools like OPTION-12 or side, low health literacy and sociocultural norms discour-
the MAPPIN’SDM observer version are more appropriate. aging disagreement with clinicians’ recommendations fur-
In Korea, validation and reliability studies are currently un- ther limit adoption [68].
derway for localized versions of tools such as the SDM-Q-9, To improve the current situation and strengthen the
SDM-Q-Doc, MAPPIN’SDM, and OPTION scales. For SDM adoption of SDM in Korea’s healthcare system—often
to be adopted as a formal quality assessment criterion in characterized by the ‘three-minute consultation’—a sys-
healthcare, cultural adaptation of these tools, together with tematic and multilayered approach is necessary. One ex-
systematic validation and standardization, must be en- ample is the Ask 3 Questions campaign developed in Aus-
sured. Once such infrastructure is established, SDM can tralia, which encourages patient participation during
advance from a theoretical concept to a practical standard clinical encounters by guiding patients to ask three key
of care, embedded into everyday clinical settings. questions. This simple strategy promotes active communi-
cation with HCPs and facilitates patient involvement in de-

Research and Policy Discussions on cision-making [69]. Evidence indicates that even such a

Shared Decision-Making in Korea straightforward intervention can significantly enhance

both the level of patient participation and the quality of in-
Globally, collaborative approaches to decision-making formation provided by HCPs [70].
between patients and HCPs are increasingly recognized as
the new clinical standard. In Korea, research and policy Future Directions
discussions on SDM have been growing steadily. For ex-
ample, in 2019, the Ministry of Health and Welfare funded For SDM to be firmly established in Korean clinical prac-
a study exploring SDM models for life-sustaining treat- tice over the long term, a comprehensive strategy is re-
ments through the National Evidence-Based Healthcare quired. This strategy must extend beyond improving the
Collaborating Agency [64]. Since 2021, under the Pa- clinical environment to include changes in HCP education,
tient-centered clinical research project, studies have been shifts in consultation culture, and revision of relevant legis-
conducted on SDM in areas such as renal replacement lation. Primary future directions are as follows.
therapy for chronic kidney disease [65] and fertility preser- First, development of Korean SDM models and educa-
vation for young breast cancer patients [66]. More recently, tional systems: For SDM to be practically implemented,
since 2023, the Korea Health Industry Development Insti- conceptual models and implementation strategies must
tute has supported a project titled ‘Development and reflect the unique characteristics of the Korean healthcare
demonstration research of the patient-doctor shared deci- environment and the patient–physician relationship. Exist-
sion-making model’ [67]. These initiatives are generating ing SDM models and frameworks should be critically re-
evidence and developing SDM models suited to the Kore- viewed and applied in Korean clinical contexts to confirm
an healthcare context. their empirical validity. Based on these insights, localized
Nonetheless, SDM in Korea remains at an early stage. SDM models tailored to cultural and institutional contexts
Many patients are unfamiliar with the concept, while HCPs can be created. Furthermore, a team-based educational

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 Kim MJ · Yoo SH · Patient-centered care and shared decision-making

system should be established that includes not only physi- nologies extend the continuity of SDM beyond the consul-
cians but also other HCPs, such as nurses and pharmacists, tation room. However, their application must be
to enable collaborative decision-making among patients, accompanied by robust ethical safeguards. Excessive reli-
HCPs, and multidisciplinary teams. ance on algorithms risks undermining patient autonomy
Second, localization and development of PtDAs: More or obscuring the transparency of decision-making. For this
PtDAs are needed that Korean patients can easily under- reason, AI should serve as a supportive tool that enhances
stand and trust. Because patients’ information needs vary communication between patients and HCPs, rather than
across cultural contexts, further research and development as an independent decision-maker. Ultimately, the ad-
are required to determine which formats and content are vancement of SDM will depend on harmonizing techno-
most effective in supporting decision-making. PtDAs must logical precision with the empathy and ethical responsibil-
include information on quality of life, prognosis, and the ity of HCPs.
impact of daily living that results from different choices.
This will enable patients to evaluate options in light of their Conclusion
personal context and values.
Third, establishment of policy and institutional support: Through sustained research and practical implementa-
To integrate SDM into clinical practice without barriers, in- tion, a Korean SDM conceptual model and supporting
stitutional support from the healthcare system is essential. strategies will be developed. With adequate policy support,
For example, pilot projects introducing reimbursement patient-centered care—where patients and clinicians col-
systems to compensate for the additional time and effort laborate as equal partners—can be achieved. The philoso-
required for SDM could be implemented. Alternatively, phy and principles of SDM should become integral to HCP
healthcare institutions could assign dedicated SDM nurses education and clinical practice. SDM is not only a critical
to assist clinical teams. It is also critical to incorporate SDM mechanism for achieving patient-centered care but also a
performance into clinical guidelines and evaluation sys- cultural shift in healthcare that reflects the ongoing evolu-
tems and to share successful case studies to encourage tion of medical ethics. By promoting patient participation
adoption among HCPs. If institutional support establishes and respecting values alongside clinical expertise, SDM
SDM as a new standard of care, it is expected to foster a enables the delivery of truly personalized medicine. In the
long-term paradigm shift and enhance patient trust in Ko- Korean healthcare system, where challenges such as com-
rean healthcare. munication gaps exist, SDM offers a key strategy to im-
Fourth, leveraging digital health and artificial intelli- prove the quality of care, strengthen trust, and reduce un-
gence (AI) technologies: Recent advancements in AI and necessary interventions.
digital health offer promising opportunities for SDM. AI-
based patient decision-support systems can process indi- ORCID
vidual patients’ health data and preferences to generate Min Ji Kim, [Link]
tailored comparisons of treatment risks, benefits, and Sang-Ho Yoo, [Link]
prognoses [71]. Such systems allow patients to clarify their
values in advance of consultations and enable HCPs to Conflict of Interest
conduct more structured and personalized discussions. In No potential conflict of interest relevant to this article was
addition, conversational AI tools, such as chatbots, are reported.
emerging as digital aids that provide real-time responses to
patient questions or function as digital coaches to help pa- Funding
tients reflect on conflicts between values [72]. These tech- This review was supported by the Korean Health Technol-

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ogy Research and Development Project grant (Grant No. complaint or lawsuit: a simulation study. Ann Emerg Med
RS-2023-KH142275) through the Patient-Doctor Shared 2019;74:126–136.
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[Link]
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Not applicable. 10. Quality Assessment Administration Division of Health In-
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