7 General discussion and summary 147 education on care decision conversations at the outpatient clinic. In this study, we trained physicians with an e-learning module and small group hands-on training with simulated patients. Patients received an email with a weblink to a web page with information about care decisions, why it is important to discuss them, how a decision is made and background information about several treatments (accessible though hyperlinks). Unfortunately, we saw no effect on our primary outcome: patient satisfaction with the outpatient clinic visit. Remarkable was the already very high satisfaction of patients before the interventions. Even though there was no effect on our primary outcome, we learned valuable lessons from this study. In the first place, overall patient satisfaction might not be the best outcome to measure the effect of interventions to improve care decision conversations. In addition, in the study design we combined this quantitative study (chapter 2) with conversation analysis of video-recording of authentic consultations (chapter 3). The inclusion rate was much lower than expected. In contact with the researcher many patients expressed they did not want to participate because of the video-recordings. This is something to take into account when you set up a study like this. Nevertheless, this study showed us that our specific training made physicians feel more prepared to discuss care decisions. Not to mention, most patients expressed that they did not feel insecure, sad or anxious when being provided with information about care decisions in the patient education, a commonly heard fear amongst physicians (2). It is noteworthy, however, that, although patients assessed the education as informative and with quite high marks (median 8), they were neutral about whether it helped them form an opinion about care decisions or helped the discussion. This raised the question “why was the patient education assessed as not helpful, if it indeed was informative?”. Last, but definitely not least, this study showed that care decisions were barely discussed at the outpatient clinic, even after our interventions. This brought up the questions: “How are care decisions discussed and what can we learn from that?” and “Why are care decision conversations not conducted more often at the outpatient clinic?”. How are care decision conversations currently conducted? In chapter 3, we used conversation analysis to study video-recordings of authentic conversations at the outpatient clinic to investigate how often, when and how care decision conversations are currently conducted. Strikingly, the
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