Seminar 6 Medical interactions
In this topic we will be considering:
How are openings managed in medical interaction?
What sorts of questions are used during history taking?
How do doctors deliver a diagnosis?
Why is communication an important element of patient satisfaction and positive outcomes?
How important is effective communication in the code of conduct for doctors?
“The ordinary sequential organisation of conversation thus provides for displays of mutual understanding and problems therein, one running basis for the cultivation and grounding of intersubjectivity.”
Stivers T, Timmermans S. (2021) Arriving at no: Patient pressure to prescribe antibiotics and physicians' responses. Social Science & Medicine. doi: 10.1016/j.socscimed.2021.114007. Epub ahead of print.
Abstract
While the vast majority of Acute Respiratory Infections (ARIs) are viral, between a quarter and a third of adults presenting with ARIs are given an antibiotic, making antibiotic prescribing for ARIs a major contributor to the inappropriate prescribing problem. We argue that inappropriate prescribing persists because of the interplay between physicians and patients in the medical visit. Relying on a convenience sample of 68 video recordings of primary care medical visits drawn from corpora collected in 2003-2004 and 2015-2016 in the US, we show that although few patients are "demanding" or "requesting" antibiotics, many convey subtle forms of pressure through priming physicians for a bacterial diagnosis in their problem presentations; nudging towards a bacterial diagnosis during information gathering; and resisting non-antibiotic recommendations during the counseling phase. We find that patient priming, nudging, and resisting are effective strategies to influence clinical prescribing behavior. However, we also identify two ways that physicians can counter patient pressure by working to manage patient expectations through foreshadowing a non-antibiotic outcome and using persuasion when confronted with resistance. These, we show, are effective means of countering patient pressure. We argue for the dual importance of how physicians communicate and when they communicate.
Keywords: Interaction; Negotiation; Patient expectations; Persuasion; Physician-patient.
The opening question
'Two types of “How are you?” were observed. The first type was part of an everyday greeting sequence, while the second was a first concern elicitor (an expression used by the doctor to elicit the patient’s first concern). A greeting may, but need not, be produced by the doctor. A first concern elicitor, on the other hand, is necessarily produced by the doctor. Another common first concern elicitor is “What can I do for you?” A range of other elicitors were used by doctors such as: “So, what are we going to do for you today?”; “What are we talking about?”; “There we are”; “How are you getting on?”; “What’s been the trouble?” and “So”. All these were found to be variations of the standard forms “How are you?” and “What can I do for you?” '
Doctors are trained to ask open questions at the beginning of a consultation.
But rather than categorising types of questions, remember we are more interested in "what actions are being done?"
Ruusuvuori, J. (2000) ‘Control in Medical Interaction. Practices of Giving and Receiving the Reason for the Visit in Primary Health Care’, doctoral dissertation, Department of Sociology and Social Psychology, University of Tampere. Acta Electronica Universitatis Tamperensis, Finland.
In her doctoral research, Johanna Ruusuvuori found that open-ended questions only relevant for new/acute problem presentations. ie.confusion for patient if the reason to visit is to review new medication and is asked “so what can I do for you today. Medical training advises asking open-ended questions (ie wh- rather than yes/no), but the primary aim of visit determines relevance of particular types of opening questions. “eg so. you're here for last week’s test results” is a preferred opening in some contexts.
Presentation of the problem
Heritage, J. & Robinson, J. (2006) Accounting for the visit: patients’ reasons for seeking medical care. In J. Heritage & D. Maynards (Eds.) Communication in medical care: Interactions between primary care physicians and patients. Cambridge: Cambridge University Press.
‘Doctorability’ of the problem
“So at the beginning of the consultation, someone comes in with baggage and they go, “I’ve got this and I’ve got that” So that’s what they come in with, their baggage. And you’ve got to let that be put on the table. And defining what is on the table is a critical moment in the consultation. And I talk a lot about this with registrars. To get to the “Is there anything else?” question as soon as possible. And get to a “No,” to that question as soon as possible. “Have you got any other problems? Anything, any other issues?” (laughing) “Fred? No more? Right? Done? Lock it in, Freddy! Right!” And then I go on to my agenda.”
(Jonathan- Supervisor) (Stone, 2014)
Menz, F. & Plansky, L. (2014). Time pressure and digressive speech patterns in doctor-patient consultations. In E. Graf, M. Sator, T. Spranz-Fogasy (Eds.) Discourses of Helping Professions (pp. 257-288). London: John Benjamins.
Doctors in general, occupy a larger portion of speech amount than patients
When patients are given space at the beginning of the conversation, they hardly ever initiate small talk
Small talk becomes dysfunctional in the sense of prolonging the conversation only when doctors encourage it
Patients do not initiate conversation-prolonging steps during the closing phase of the conversation in the sense of the ‘door handle phenomenon’. New topics are commonly introduced in the core of the interaction.
If new aspects are introduced during the closing phase, this is done by the doctors.
Transfer of interactional control
‘mm hm’ ‘uh huh’ ‘okay’ ‘right’
(continuers) (shift-implicative (Beach 1993))
