2 The effect of training and education at the outpatient clinic 39 in insufficient power to detect a possible effect. Another explanation may be the low number of care decision conversations, possibly diluting any effect. Furthermore, patient satisfaction is influenced by many factors (35). We tried to minimize the influence of unrelated aspects by specifically directing the two questions on patient satisfaction to the conversation with the physician and the information given rather than measuring overall satisfaction, but this does not completely exclude other influences. Moreover, patient satisfaction scores without any of the interventions were high, with a median of 8.5 (IQR 8.0-9.0). It is harder to improve satisfaction, if satisfaction is already very high (36). Finally, it could be the case that the interventions under study are not sufficient in improving care decision discussions, and therefore did not result in a statistically significant effect. Patients’ general attitude towards the conversation aid was positive. Patients considered the conversation aid informative. Yet, they did not assess it as helpful in forming an opinion about care decisions or discussing them. A potential explanation can be that processing the information and forming an opinion requires more time, in which case the conversation aid might still have planted a seed for further consideration. Physicians are often afraid that introducing the topic of care decisions makes patients anxious or insecure (5). It is reassuring that most patients reported that they did not feel insecure, sad or anxious when being provided with information about care decisions in the conversation aid. Physicians indicated they felt more prepared to discuss care decisions after the training. The fact that this difference was not seen in separate important components of care decision discussions raises questions about whether the physicians actually were better prepared for these conversations, especially as it is known self-assessment has a poor agreement with externally assessed performances (37,38). However, the feeling of being unskilled or inadequately trained is a known barrier to discuss care decisions (5). Therefore, we consider the feeling of being better prepared an important step to remove this barrier and thereby improving care decision conversations. The strength of our study lies in the outpatient clinic setting we studied. Most research on care decisions is conducted in end-of-life settings, although it is considered essential to start discussing this in an earlier stage (2).
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