63 Studying physician culture in SDM Introduction Over the past decades, societal developments have propelled the interest in shared decisionmaking (SDM) in medicine. [1] Treatment choices are no longer solely made by doctors but by involving patients in this process. [2, 3] Healthcare has thus moved from a primarily doctor-centered system towards a more patient-centered system. SDM is an approach that involves at least two participants: the patient and the healthcare provider. Both parties actively participate in the decision-making process. They share information before reaching a consensus on treatment choices to be made. [1] This short definition, however, only partially addresses the complexity of the SDM process. According to Charles and others, SDM requires a doctor to establish an atmosphere for patients to share their views, followed by physicians actively eliciting patient preferences. Physicians should subsequently provide information on treatment options, risks, and benefits appropriate for this patient (p.687). [1] To complicate matters, it is often unclear how much or what type of information a patient wants. Therefore, SDM requires doctors to actively explicate patient needs before discussing options and making decisions. [1] Contemporary research has explored several important issues relating to the implementation of SDM. Examples are the definition of required competencies for doctors in implementing SDM principles, [4] identifying barriers to implementation, [5] and developing decision aids. [6] Health outcomes have been investigated as well. Patients, for example, show better adherence to treatment, and both patients and healthcare professionals show more satisfaction when using SDM. [7] This could potentially lead to more positive effects on disease-related outcomes as well, [7] although empirical research to prove these effects is lacking. [8] Despite all the efforts to implement SDM in medical practice, it has never reached the desired level of embedment in usual patient care. [8] Practitioners, for example, only partially and inconsistently use decision aids correctly. [9] Furthermore, deliberation and joint preference construction are not standard practice in decisions to use high-impact treatment modalities like chemotherapy. [10] Physicians have even shown resistance to the changes required to execute SDM correctly. [8, 11] The reasons why doctors are reluctant to implement changes, and SDM in particular, are not fully understood. Yet, research indicates physician culture, expressed in a set of shared beliefs, knowledge, and practices, might be of great importance. [11] However, studies into physician culture are rare. One reason for neglecting culture in SDM research may be that the sociocultural environment is difficult to grasp. Its presence is rather implicit, with complex interactions and vague descriptions. Using scientific methodology from social sciences could help us better understand the concept of culture, as it provides notions and insights on how to explain its presence. This study uses the work of French sociologist Pierre Bourdieu and his concepts of habitus, field, and capital as a lens for explicating physician culture relating to SDM principles. [12] An ethnographic study was performed, identifying elements that might predict or even stipulate 4
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