71 Studying physician culture in SDM In general, physicians often presented themselves in patient encounters as representatives of a team of doctors. They even tended to speak in terms of ‘we’ rather than ‘I’. In the case described in Box 1, the resident, for example, referred to ‘our advice’, instead of ‘my advice’. The following quote is another example of how the team’s voice was presented in a patient encounter. It also illustrates how the group recommendation is presented to the patient first before eventually tuning in on the patient’s perspective. A patient who is currently being treated with chemotherapy for ovarian cancer checks in for a follow-up visit. Doctor: “When considering surgery, like in your case, we look at three important issues. First, what we see on the scan, which has been positive since the start of your chemotherapy. Next, we look at your blood values, which have improved. And lastly, how you feel. We think it is better for you to have the surgery. But we also want to know how you feel”. (Source: observation of a patient encounter) Knowing what the patient wants Doctors often seemed to think they knew what was best for their patients. On the one hand, this might be true since they seemed very involved with their patients. On the other hand, doctors often fill in patients’ wishes beforehand, based on clinical patient characteristics and without explicitly asking what the patient wants, especially in first-patient encounters. This filling in for patients may have to do with logistics around newly referred patients, as the case in Box 1 also illustrates. The hospital under study is a referral center for treating gynecological malignancies, so part of the diagnostics is usually performed elsewhere. As one nurse describes: “When another hospital refers people, we already start to plan their treatment. And when we start acting, we have only seen them once. So how well do you know someone?”. (Source: interview with a specialized nurse) The first consultation in the hospital under study often concluded with determining the next steps in the diagnostic workup or even definitive treatment planning. It often lacked a full exploration of treatment options. For example, the option ‘no treatment’ was rarely given. One doctor commented that patients would not have been referred if they did not want any treatment but admitted to not always check whether this actually was the case. The following example illustrates how treatment decisions may lead to an unwanted result: Nurse: “I once spoke with a woman who had (major surgery). (…) She said: ‘If I had known this beforehand, I would never have initiated the surgery.’ It is difficult for people to imagine what it does to you when you are in the midst of it. Because you do not know what it does to a patient’s life.” (Source: interview with a specialized nurse) 4
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