Chapter 3 60 analyze. Furthermore, the conversations were not evenly distributed over the participating physicians: some had not a single conversation about care decisions while one physician introduced the topic of care decisions in ten consultations. This may have influenced our observations: this physician’s personal preference about how to discuss care decisions could have been interpreted as a common practice simply because we observed it with more frequency. However, because we saw different patterns in this physician’s consultations and similar patterns in the conversations of the other physicians, we do not believe this impacted our analysis. Because of the small number of patient-initiated care decision conversations, it was difficult to draw conclusions about how patients introduce the topic. It is, however, remarkable that patients almost never do so, perhaps because they believe the physician will take the initiative if and when the topic becomes relevant [11]. 4.2 Conclusion We observed that care decisions are rarely discussed during consultations at a general internal medicine outpatient clinic. There is no destined phase in the consultation to initiate this topic, and it involves considerable effort and (external) accountability to create common ground and to solve the relevance paradox. The topic is often framed as an alien, administrative matter. 4.3 Practice implications Although the importance of discussing care decisions has been recognized [2], our study shows that the frequency of these discussions in our dataset of 150 video recordings at the internal medicine outpatient clinic is low. Education and training are therefore needed. Our physician training and patient education program, which focused mainly on emphasizing the importance of care decision conversations, improved the frequency of care decision conversations. Our analysis illustrates the need to devote more attention to three problems: 1) an interactional slot has to be created to introduce the care decision topic; 2) common ground has to be created and found; 3) the paradox of the topic as ‘relevant in the future’ but ‘needs to be discussed now’ needs to be overcome. Although our study shows no definite solution, we would like to share ideas
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