Pre-training clinician survey to assess prior experience with SDM:
Today’s date:__________________________________________________
Your name (please print legibly): ___________________________________
Your email address:_____________________________________________
Location of your practice: ________________________________________
What is your age (in years)?
____ years
What is your degree?
____ DO (Doctor of Osteopathic Medicine)
____ NP (Nurse Practitioner)
____ PA (Physician Assistant)
____ Other; Please specify: ___________________________
In what year did you receive this degree? _________
What is your gender?
____ Female
____ Male
____ Transgender: Identify as female
____ Transgender: Identify as male
____ Other
____ Prefer not to answer
What is your race? Please mark all that apply.
____White
____Black or African-American
____Asian
____Native Hawaiian or other Pacific Islander
____American Indian or Alaskan Native
____Other, please specify:
____Prefer not to answer
Are you of Hispanic, Latinx, or Spanish origin?
____Yes
____No
____Prefer not to answer
What is your medical specialty (e.g., Family Medicine, Internal Medicine, Cardiology, etc.). Please list all: ______________________________________________________________
How many days (or half days) do you see patients in a typical week? ___ days per week
How many patients do you see in a typical day? _______ patients per day
Sometimes medical action is clearly necessary, and sometimes it is clearly not necessary. Other times, reasonable people differ in their beliefs about whether medical action is needed. In situations where it’s not clear, do you tend toward taking action or do you tend toward waiting and seeing if action is needed?
I strongly lean toward waiting and seeing 1 |
2 |
3 |
4 |
5 |
I strongly lean toward taking action 6 |
Have you ever received any additional training beyond residency in how to engage in shared decision making with your patients?
___ Yes
___ No
10b. If you said ‘Yes’ to #10, briefly describe the training you received and where/how you received it: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________
How confident are you that you understand what shared decision making is?
___ Not at all confident
___ Slightly confident
___ Somewhat confident
___ Fairly confident
___ Completely confident
How confident are you in your ability to engage in shared decision making with your patients?
___ Not at all confident
___ Slightly confident
___ Somewhat confident
___ Fairly confident
___ Completely confident
How often do you currently engage in shared decision making with your patients?
___ Almost always
___ Often
___ Sometimes
___ Rarely
___ Never
Excluding emergency situations, how often do you think patients’ preferences should be taken into account when making clinical decisions?
___ Almost always
___ Often
___ Sometimes
___ Rarely
___ Never
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Elinor Brereton |
| File Modified | 0000-00-00 |
| File Created | 2021-08-02 |