75 Studying physician culture in SDM practice are scarce; therefore, it is hard to compare results or even find similarities across studies. The previously mentioned study on surgical culture, for example, paints a more negative picture than our study [29] with traits like harshness and invulnerability, which we did not recognize in our study group. One interview study among obstetricians confirmed that how healthcare is organized could potentially hamper SDM. It demonstrated that fragmented and emergency care, with little time for doctors to get to know their patients, sometimes leads to misjudging patient preferences. [33] This finding could explain why care is tailored more to individual differences later in the patient workup when doctors get to know their patients better, as was observed in the current study. Another report on the same interview study showed that obstetricians felt confident to base their decisions on their own clinical expertise and patient choice instead of adhering to guidelines. [37] However, it also reported reasons for doctors to adhere to guidelines instead, in situations where they did not want to. The reasons mentioned were pressure from colleagues or a fear of lawsuits. [37] The fear of lawsuits was not observed in the current study, yet this could vary from country to country, as the respective judicial systems (e.g., the judicial capital) differ. Meaning of the study The novelty of this study is that a different approach was used to assess SDM execution in practice. Understanding how physician culture, defined by habitus, field, and practice, affects doctors’ behaviors, provides new clues on how to change practice toward better execution of SDM principles. One suggestion would be to give explicit attention to the patient’s preferences in the early stages of patient workup by spending more time getting to know the patient before treatment advice is discussed. Tumor board meetings and other team meetings should be reviewed and redesigned to support both SDM and EBM principles, for example, by giving formal attention to patients’ individual context and preferences. Furthermore, guidelines and medical education should pay more attention to patient perspective and how to deal with uncertainty, moving away from the current rationalistic approach. Future research This study was executed in a single department with a specific group of doctors in a highly specialized care field. More ethnographic studies should be performed to validate study findings in other settings. Future interventions for promoting SDM could then be tailored according to study findings. Implementation studies should further test whether the proposed changes in field and capital indeed lead to better execution of SDM principles. Acknowledgments The authors want to thank the doctors and nurses working at the Radboudumc gynecological oncology department for participating in this study. 4
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