69 Studying physician culture in SDM A few other hospitals are also presenting their cases in this meeting through video conferencing. Mrs. X is now presented by the referring hospital, focusing on pathology results and the presumed following diagnostic and therapeutic procedures. It is 1:30 p.m., and Mrs. X is now consulting her physician. She heard only a week ago that she suffered from a malignancy and is very emotional. She says that she is devastated and that she does not understand why this is happening to her. “I just had my breasts examined, and they were fine!”. Her husband accompanies her, and while she is crying, he is mainly quiet. The woman states that she keeps thinking the worst will happen to her and that she “does not want to know everything”. The consulting physician, who is the same resident presenting in the morning meeting, tries to reassure her by explaining what will happen today and the following weeks. Next, the patient’s history is discussed, followed by a physical examination. During the examination, one of the gynecologists joins the consultation. Afterward, the resident and the gynecologist explain to the couple what the treatment plan will be. “Our advice would be to perform surgery. A tumor is present, but it will not be difficult to remove. We will also remove lymph nodes from the groin during the surgery.” The resident gives a technical explanation of the procedure and possible complications. Mrs. X asks many questions, e.g., “What if I do not wake up from the anesthetic?” and “What if they cannot find the right lymph node?” The resident tries to reassure the patient, “The chances you will be cured are really good”. “I trust you”, the patient finally states. At the end of this consultation, which took about 45 minutes, Mrs. X is seen by a nurse who provides more information about the procedures. She gets an appointment for an ultrasound and a meeting with the anesthesiologist, and ultimately her surgery is scheduled. At the end of the afternoon, a debriefing takes place with all residents and gynecological oncologists present. Again, all new patients are discussed, including Mrs. X. The resident briefly describes her workup, now also mentioning that the patient was very emotional. One of the gynecologists asked the resident what she would do if the tumor was slightly different in size. When the resident does not give the ‘right’ answer, she is told to look it up again in the guidelines. The emphasis on medical evidence was also visible beyond formal meetings and patient visits. The hospital where this study was executed is a teaching hospital where medical trainees and gynecology residents are trained. This training clearly emphasized medical knowledge. Residents were, for example, actively encouraged to familiarize themselves with reigning guidelines for oncological care, as seen in Box 1, but not structurally coached on how to deal with patient wishes. Furthermore, the specific guidelines for gynecological oncology care did not incorporate patient perspectives in the diagnostic workup and showed only minor variation in treatment 4
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