Addressing epistemic injustice in Shared Decision-Making: Learning from Underserved Patient Groups to Foster More Equitable Healthcare

Abstract INTRODUCTION: Shared decision-making (SDM) is a hallmark of equitable, patient-centered care, yet inequitable practices and social disparities in patient participation remain. Underserved patients’ perspectives can illuminate the differential impacts of SDM implementation on patient participation across strata of society and make the formats and conditions that hinder their participation more visible. OBJECTIVE: This study explored underserved patients' experiences with SDM and their ideas for addressing the experienced drivers of exclusion, aiming to (1) identify factors excluding underserved groups from SDM participation and (2) uncover opportunities to reduce them. METHODS: This qualitative study, part of a broader Targeted Intervention Planning (TIP) project, engaged fourteen underserved patients in a group brainstorming session combining patient journey mapping and the nominal group technique. Data included the recorded session, individual debriefing interviews, and written participant notes, analyzed using interpretive description and Braun and Clarke's thematic analysis. RESULTS: Patients most frequently cited feeling dismissed ("the doctor does not take me seriously") and time pressure as drivers of exclusion. Six themes emerged: dismissiveness, system pressure, communicative misalignment, disrespectful behavior, assertiveness, and healing experiences. Findings pointed to epistemic injustice—patients' diminished credibility and interpretive gaps in patient-provider communication—as an underlying mechanism, compounded by structural pressures on healthcare systems. CONCLUSION: Epistemic injustice, shaped by social identity, intersecting vulnerabilities, and systemic constraints, appears to be a key, underrecognized driver of underserved patients' exclusion from SDM. Addressing these epistemic and structural preconditions is essential for enabling equitable patient-provider communication and truly equitable SDM in clinical practice.