Objectives To revise an existing three-talk model for learning how to achieve shared decision making, and to consult with relevant stakeholders to update and obtain wider engagement. Design Multistage consultation process. Setting Key informant group, communities of interest, and survey of clinical specialties. Participants 19 key informants, 153 member responses from multiple communities of interest, and 316 responses to an online survey from medically qualified clinicians from six specialties. Results After extended consultation over three iterations, we revised the three-talk model by making changes to one talk category, adding the need to elicit patient goals, providing a clear set of tasks for each talk category, and adding suggested scripts to illustrate each step. A new three-talk model of shared decision making is proposed, based on “team talk,” “option talk,” and “decision talk,” to depict a process of collaboration and deliberation. Team talk places emphasis on the need to provide support to patients when they are made aware of choices, and to elicit their goals as a means of guiding decision making processes. Option talk refers to the task of comparing alternatives, using risk communication principles. Decision talk refers to the task of arriving at decisions that reflect the informed preferences of patients, guided by the experience and expertise of health professionals. Conclusions The revised three-talk model of shared decision making depicts conversational steps, initiated by providing support when introducing options, followed by strategies to compare and discuss trade-offs, before deliberation based on informed preferences.

Findings from this single site study suggest that provider discomfort and avoidance are important barriers to evidence-based brief alcohol counseling. Further investigation into current alcohol counseling practices is needed to determine whether these patterns extend to other primary care settings, and to inform future educational efforts.

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Shared decision making occurs when patients and clinicians reach a formulation about the presenting problem and discuss how to manage it. If there are several reasonable alternatives, the alternatives should be explicitly compared, using evidence about relevant harms and benefits. Such decisions should be informed by knowledge about the patients' condition, about the evidence applicable to it, and the patient's goals and preferences. Eliciting patients' views has been referred to as making a preference diagnosis, 1 and eliciting it requires a blend of science and interpersonal skills.The term shared decision making began to appear in health care discourse in the early 1980s, hard on the heels of the term patient-centered care. In the late 1990s a number of articles advocated for its central place in clinical practice. This led to a surge of academic interest, fuelled by the parallel innovation of patient decision aids, tools that help inform patients about options. Mention of shared decision making and patient decision aids in the Affordable Care Act (ACA) in 2010 initiated a policy emphasis on this approach.In these publications (academic articles and in documents such as the ACA) shared decision making is often presented as an ethical imperative. There is evidence of the impact of shared decision making on patient outcomes. 2 Evidence from clinical trials on the use of patient decision aids, often viewed as a proxy for a shared decision making process, provides evidence that they improve patient knowledge and risk perception and lead to higher-quality decision quality. 3 There is also increasing evidence that decision aids can enhance adherence to recommended care 2,4 and that that health care costs may decrease in some situations. 3,5 There are gaps in research, such as how to encourage clinicians to achieve meaningful shared decision making rather than merely checking a box in the patient's electronic health record. Evidence summaries should minimize bias and offer recommendations that take into account the role of patient preferences. 6 Undertaking shared decision-making is a cultural shift-which is difficult to achieve when clinicians feel pressured by their workload and the burdens of clinical documentation.It is essential to understand a patient's preferences, including the role he or she wants to play in decision making. Without a sense of what each patient prefers, it is impossible to provide care that fits the individual's situation. When medical evidence does not support a single option, patients should be informed