3 Conversation analysis of authentic care decision conversations 53 3.3 How the topic of care decisions is initiated Because most care decision conversations were physician-initiated (17 out of 21), we focus on the physician-initiated conversations in this section. We provide two illustrative examples from our data. Throughout our data a problem is visible with creating relevance for the introduction of the care decision conversation. Physicians provide several justifications or accounts [23] for this introduction, although– in the institutional context of a consultation – they have privileged opportunities to ask a patient health-related questions [24]. Physicians use two distinct strategies: external accountability or patientrelated accountability. In external accountability, the physician uses sources outside of the patient’s health domain as justification. Most frequently used is participation in this study/presence of the camera in the consultation room (10 out of 17 consultations). Other examples are that information about care decisions is currently missing in the system/electronic health record (EHR) or referral to hospital policy on discussing and documenting agreements on care decisions. In patient-related accountability, physicians provide justifications connected directly to the specific patient (e.g. a reference to something the patient has said before, the patient’s impaired physical condition or a recent event such as surgery). An example of this is ‘some people have - because you have also had a heart surgery - have ideas about whether or not they want this’. In the first example, the topic of care decisions is introduced in the ‘treatment and course of disease’ phase with use of external accountability.
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