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A three-talk model for shared decision making: multistage consultation process

BMJ 2017; 359 doi: (Published 06 November 2017) Cite this as: BMJ 2017;359:j4891
  1. Glyn Elwyn, professor1,
  2. Marie Anne Durand, assistant professor1,
  3. Julia Song, research assistant1,
  4. Johanna Aarts, research clinician2,
  5. Paul J Barr, assistant professor1,
  6. Zackary Berger, associate professor3,
  7. Nan Cochran, associate professor1,
  8. Dominick Frosch, chief care delivery evaluation officer4,
  9. Dariusz Galasiński, professor of discourse and cultural studies5,
  10. Pål Gulbrandsen, professor6,
  11. Paul K J Han, director7,
  12. Martin Härter, professor8,
  13. Paul Kinnersley, professor9,
  14. Amy Lloyd, research fellow10,
  15. Manish Mishra, assistant professor1,
  16. Lilisbeth Perestelo-Perez, senior researcher11,
  17. Isabelle Scholl, Harkness fellow1,
  18. Kounosuke Tomori, associate professor12,
  19. Lyndal Trevena, professor13,
  20. Holly O Witteman, associate professor14,
  21. Trudy Van der Weijden, professor15
  1. 1The Dartmouth Institute for Health Policy and Clinical Practice, Williamson Translational Research Building, Lebanon, NH 03756, USA
  2. 2Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, Netherlands
  3. 3Johns Hopkins School of Medicine, Division of General Internal Medicine, Baltimore, MD, USA
  4. 4Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
  5. 5Faculty of Arts, University of Wolverhampton, Wolverhampton, UK
  6. 6Institute of Clinical Medicine, University of Oslo, HØKH Research Centre, Akershus University Hospital Sykehusveien 25, Lørenskog, Norway
  7. 7Center for Outcomes Research & Evaluation, Maine Medical Center, Portland, Maine, USA
  8. 8University Medical Center Hamburg-Eppendorf, Department of Medical Psychology, Hamburg, Germany
  9. 9Centre for Medical Education, School of Medicine, Cardiff University, Cardiff, UK
  10. 10Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Cardiff, UK
  11. 11Evaluation Unit, Canary Islands Health Service, Camino Candelaria, El Rosario, Tenerife, Spain
  12. 12Department of Occupational therapy, Tokyo University of Technology, Nishikamata, Ohtaku, Tokyo, Japan
  13. 13Discipline of General Practice, Sydney School of Public Health, University of Sydney, NSW, Australia
  14. 14Department of Family and Emergency Medicine, Université Laval, Quebec, Canada
  15. 15Department of Family Medicine, School CAPHRI, Maastricht University Medical Centre, Maastricht, Netherlands
  1. Correspondence to: G Elwyn glynelwyn{at}
  • Accepted 18 October 2017


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.


  • We thank Adrian Edwards, Anne Stiggelbout, Natalie Joseph-Williams, and members of the Preference Laboratory at The Dartmouth Institute for Health Policy and Clinical Practice for comments on this model.

  • Contributors: GE and MAD conceived and designed the study. GE, MAD, and JS collected, analyzed, and interpreted the data. All authors drafted, critically revised, and gave final approval of the model and article. GE acts as guarantor.

  • Funding: This work was not supported by an external award.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: This study was approved by the Dartmouth College Committee for the Protection of Human Subjects (STUDY00030085).

  • Data sharing: No additional data available.

  • Transparency: The guarantor (GE) affirms that the manuscript is a honest, accurate, and transparent account of the study bring reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

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