117 General discussion Chapter 4 highlighted the prevailing issue of misinterpreting established definitions and applications in evidence-based medicine (EBM) and SDM. EBM is frequently oversimplified by emphasizing medical evidence at the expense of individual patient contexts. A similar trend was observed in SDM throughout all preceding chapters. SDM is often reduced to merely distributing decision aids or following a 4-step protocol during consultations, as depicted in Figure 1, disregarding its inherent complexity. Reductionism also manifested itself differently in Chapter 6. Change processes like SDM implementation are sometimes – inaccurately – perceived as automatically occurring once barriers are addressed. However, this does not align with the practical realities of SDM implementation as presented in present-day SDM literature. These cumulative findings underline the pressing need for a more comprehensive approach when implementing SDM. Figure 1: A 4-step approach toward shared decision-making (SDM). Based upon the work of Stiggelbout et al. (2015) and Elwyn et al. (2017). In conclusion, implementing SDM calls for expanded use of sociological, psychological, and behavioral theories, acknowledging the cultural factors influencing physician behavior, and understanding the role of cognitive dissonance in SDM engagement. Chapter 6 offers a structured approach to address conflicting beliefs, which includes practice assessments based on behavior change theory, open discussions regarding SDM’s utility and appropriateness, and the promotion of lifelong reflective practice. Critical reflection While this thesis covers a broader range of topics, it is important to note that certain concepts are only briefly touched upon. Nevertheless, we delve more deeply into some concepts encountered along the way. After conducting a thorough review of the research findings in this thesis, four prominent themes emerged, each offering valuable insights for current and future SDM implementation initiatives. The first theme concerns the misconception that training alone is a panacea to prevent SDM failure. The second theme pertains to the prevalent reductionist approach that the field of medicine often takes towards SDM, along with the inherent challenges 7
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