67 Studying physician culture in SDM Patient and public involvement statement No patients or public were involved in the design of this study. Results As with all hospital ethnographies, it is impossible to fully describe all observational results. Physician practice is therefore illustrated by picturing a typical patient workup at the gynecological oncology department (see Box 1). The case is fictional, yet it combines elements from real observations to illustrate practice and to provide a background for the rest of the description of the results. Figure 1 subsequently shows key features of gynecological oncologists’ habitus, capital, and field identified in this study. These particular features resulted from the thematic analysis and were selected as they seem related to how SDM was executed. The three elements from doctors’ habitus are further described in our results section, as they refer most to doctors’ practice. This results section will not elaborate on capital and field as separate themes. Emphasis on medical evidence During the observations, it became apparent that medical evidence, mostly obtained from clinical trials, played a key role in the doctors’ daily practice. This finding fits well with elements from capital and field. The Dutch medical training system is based on evidence-based medicine (EBM) principles, and gynecological oncology is a strictly regulated field of care. Especially in tumor board meetings, many references were made to results from medical studies and evidence-based guidelines, mainly to determine the ‘right’ diagnostic procedure or treatment protocol for an individual patient. The patients’ wishes and perspectives were sometimes explicitly mentioned but were not given structural attention. When doctors and nurses were asked to comment on the lack of patient perspective in board meetings, reasons mentioned were lack of time, that the meetings were meant for representing ‘medical data’, and that, according to them, the patient perspective was sufficiently represented in these meeting through the presence of a nurse as the patient’s case manager. In practice, however, these nurses rarely contribute to the discussion. As one of the nurses stated: “During tumor board meetings, we are always in a hurry, so you cannot elaborate on every patient. So, yes, the conclusion often is a medical conclusion. Context is eventually discussed in the conversation with the patient.” (Source: interview with a specialized nurse) In doctor-patient encounters, the same tendency to emphasize medical evidence was observed. Although patients were often asked about their perspectives, first encounters often emphasized ‘what is best practice’ in terms of treatment decisions based on guidelines and other medical evidence. In the case described in Box 1, for example, no alternatives were discussed besides the workup advised within the guidelines for treating vulvar cancer. 4
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