Chapter 2 38 In summary, neither of the interventions had a statistically significant effect on patient satisfaction, patient-doctor relationship and extend of shareddecision-making experienced by physicians. Physicians felt statistically significant more prepared to discuss care decisions after training and patients evaluated the conversation aid positively. 4. Discussion Neither of the interventions had a statistically significant effect on patient satisfaction, patient-doctor relationship and extent of shared decisionmaking experienced by physicians. Patients considered the conversation aid to be informative and easy to understand without causing insecurity or anxiety. Furthermore, physicians felt better prepared to discuss treatment decisions after the training. With the interventions under study, we aimed to stimulate patient empowerment, patient-centred care and meaningful discussions on care decisions, all hopefully resulting in more satisfied patients. We deliberately refrained from using number of care discussions as study outcome as discussing care decisions just to ‘check off a box’ does not improve patientcentred care and leads to frustration and pressure in physicians (31). We aimed to plant a seed, to stimulate patients to think about their preferences and to create common ground to start the conversation; not to force them to reach an immediate decision. Although it was not the focus of our study, the low proportion of patients reporting to have discussed care decisions (28%), of which about half made a decision during the outpatient clinic visit, is remarkable. These low numbers might be explained by the perception that it is ‘too soon’ or ‘not yet relevant’ to discuss care decisions (32–34). Besides, previous research showed physicians often miss openers from patients that could have prompted these discussions (11). Our qualitative analysis shows that care decisions is a precarious topic for which there is no obvious interactional slot. Therefore, effort is needed to introduce the topic and create common ground (13). There are several possible explanations for the absence of a statistically significant effect of the interventions on the mean patient satisfaction. First, we did not reach the intended sample size. This could have resulted
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