65 Studying physician culture in SDM The observations mainly focused on a team of six gynecological oncologists, three residents, and two specialized nurses. The researchers observed various group specialist meetings and individual doctor-patient encounters. Field notes were taken during observations and processed afterward. [19] Field notes were discussed with the project team at least every three weeks. Data collection and analysis Data collection, processing, and analysis were done simultaneously throughout the whole observation period. Emerging themes from observations and interviews were used to structure future observations and activities. [17] Data collection was divided into three phases, each phase containing at least one team meeting (LS, SV, TG, AA, FS, DB; in changing group compositions). In phase 1, the researchers introduced themselves to the field and performed exploratory observations. [17] Most observations during this phase were done simultaneously (LS, SV). Field notes were thematically coded by the researchers separately (LS, SV). Next, notes and themes were compared and subsequently refined in a code list through an iterative process. This list was then used to design more structured observation forms to be used in the next phase. In phase 2, data was collected with the help of these forms (see Observations forms phase 2 in Appendix 1). Both researchers now started performing separate observations. Furthermore, a semi-structured interview guide was developed, reflecting some previously emerged themes from phase 1. The interview guide contained questions on the use of SDM, as well as two hypothetical clinical cases, and is added in Appendix 2. For the cases, the interviewee was asked to elaborate on two fictional patient workups, including their decision-making process. After discussing the first results at the start of phase 3, the observation forms were redesigned, including a checklist with key elements in SDM, [20] and a checklist on interprofessional attitudes to aid the interpretation of observations (see checklists added in Appendix 3). [21] Next, final observations and interviews were performed. A total of nine formal interviews were conducted with five gynecologists, two residents, and two specialized nurses. Finally, national guidelines for gynecological oncology care were examined, focusing on the presence of SDM principles. [22] At the end of data collection, all observational notes and interview transcripts were thematically analyzed and discussed in a team meeting. Bourdieu’s Theory of Practice This study starts with the assumption that medical culture influences the practice of SDM and that physicians are socialized in this culture through formal and informal ways. It uses Bourdieu’s ‘Theory of Practice’, with its concepts of habitus, field, and capital, to explicate 4
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