Table 2.

Theme Summaries with Supporting Quotes from Patients and Primary Care Providers

Theme	Sub-theme	Patient exemplar	PCP exemplar
While desiring SDM, patients and PCPs expressed knowledge barriers to implementing it.	A perceived lack of technical and process knowledge gave PCPs greater decision-making power, but could threaten trust.	“I mean I do not even know what [mammograms] are, so I would not say it would be on a patient, because they are not knowledgeable to medical stuff as much as a doctor would be.”	“So if I tell them, ‘You need a mammogram,’ they are going to do it– even if they do not know what it is, even if they do not think it’s valuable...So I try to give them more information, so that they will not just be doing it because I say so.”
	Concerns about patient capacity to understand comprehensive information curtailed SDM.	“Sometimes they use a word you are not familiar with, and you hear it again and you are like, ‘Okay I remember what that means’... So I actually kind of do like the terms that they use, because at least I know how to actually say something right if I do remember.”	“I think we get away from it should be a shared decision-making conversation... We should be doing appropriate counseling on the risks and benefits of it. And I think for the majority of the visits we are like, ‘Oh, you are due for a mammogram. I’m just going to put that order in.’”
Most patients sought technical and process knowledge; PCPs acknowledged that these elements were undercommunicated.	There was a desire for providing patients with process and technical knowledge.	“I think if people talked about the steps, that’s important … I do not think anybody explains that. It’s just go get your mammogram, make the appointment.”	“What is it they are actually doing? We do that for everything else that we do procedurally for patients, but mammograms we are just like, ‘Here’s your order for your mammogram. Go get a mammogram’… nobody really prepares them.”
	There were misperceptions about the accuracy of mammograms.	“They’re going to tell you what you have. It’s not bad. I mean something that hurts… But [it will] tell you what you have, what you can do, they tell you everything.”	“I feel like I spend a lot of time allaying anxiety because I think the scientificness of the process gives this idea that I somehow have a crystal ball.”
Mammograms were perceived to be a well-known test, which was a barrier to addressing patients’ informational needs during visits.	Mammograms are in the public discourse and well-understood.	“Even if there is nothing there they should go into it more, I mean like on the basics... because I kind of feel dumb right now. Like I know, but I do not.”	“I would say 100% literally, regardless of the language that they speak or their education level, understand what a mammogram is… It’s really kind of permeated cultures so that people understand that.”
	Assessing understanding was curtailed due to the perception that mammography was understood.	“If somebody just saying, ‘Yeah,’ but they really do not understand, they [doctors] will not say, ‘Do you understand what I’m saying?’ Make sure to ask them. Do not wait until the end and get upset when they are asking and they say, ‘I just told you.’ I did not know what that was.”	“Especially when there’s the interpreter line. That’s like a huge barrier in all routine health … There’s been times when I’m like I do not know if they truly understood what I was trying to say…Occasionally, I’ll try teach back … but other times, just kind of move along with the visit because there’s a lot of other things to tackle.”
Systems-level issues across healthcare settings discouraged PCPs from tailoring mammography recommendations and confused patients.	Conflicting information led to confusion.	“When the nurse practitioner asked me again… it was kind of—not a shock, but I wasn’t aware that she’s going to ask me to get a mammogram. Because in my head, we have to do it at age 50.”	“I would say that would be one of the biggest things is the diversity of how much the guidelines change, and the fact that they are all kind of conflicting, it makes it easy for patients to doubt providers.”
	Information provided ahead of the visit would better support SDM.	“They should give classes on it to patients so they’ll know what to expect. That way their doctors will not have to explain it to them. They could show a movie of mammogram… or explain to the class about what a mammogram is and how to go about getting a mammogram, what to expect.”	“It would be nice if the patient comes in having some [information] … So then you can start a discussion at a different time… If you have somebody that has read something… you can have a different conversation.”
	Post-visit supports are needed.	“I mean, even if they just put in information for patients [on the patient portal] - materials to read on what you should be doing, next step, preventive care, you should be on time for this maybe six months or a year…so that they are not always trying to get the doctor on the phone.”	“There’s no good summary of this is what you decided for your routine health maintenance after this visit. So if there was an easy way to click and say, ‘we decided you are going to,’…and just to say this is actually the result outcome of our shared decision making around cancer.”
	Non-clinical staff can support information-sharing.	“You do not have to be a doctor. It could somebody like a nurse practitioner or just a counselor who works in that area all about that for women with mammograms.”	“I’m not using any sort of specialized clinical knowledge... “I’m just using a model, an algorithm to say like, ‘You fall into this category you do this…’ And really like a lot of people could do that... You do not have to have an MD next to your name to be able to do that.”