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Paulus TM, Grubbs H, Rice-Moran R, Lester JN. How student healthcare providers in a communication skills course respond to standardized patient resistance. Soc Sci Med 2023; 337:116309. [PMID: 37879265 DOI: 10.1016/j.socscimed.2023.116309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 10/02/2023] [Accepted: 10/05/2023] [Indexed: 10/27/2023]
Abstract
Encountering and responding to patient resistance can be especially challenging for student healthcare providers. Navigating who ultimately holds the authority to know and understand a health concern, make recommendations for a course of action, and accept or resist these recommendations are all part of how epistemic authority is negotiated in medical settings. The purpose of this paper is to systematically examine how student providers enrolled in a communication skills course at an American university responded to standardized patient resistance. The data for this study were 121 video-recorded and transcribed final objective structured clinical examinations from the fall 2019 course. We used discourse analysis informed by principles of conversation analysis to identify several discursive strategies used by the students, including: 1) asking for clarification; 2) expressing uncertainty and offering to gather additional resources; 3) aligning with and offering an account for the resistance; 4) recommending a new course of action; and 5) confronting the resistance. Our findings point to the value of including instruction for both student healthcare providers and standardized patients on how to respond to resistance they encounter in ways that may help improve healthcare outcomes.
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Affiliation(s)
- Trena M Paulus
- East Tennessee State University, Research Division, Department of Family Medicine, Quillen College of Medicine, PO Box 70621, Johnson City, TN, 37614, USA.
| | - Heather Grubbs
- East Tennessee State University, Research Division, Department of Family Medicine, Quillen College of Medicine, PO Box 70621, Johnson City, TN, 37614, USA.
| | - Renee Rice-Moran
- Department of Curriculum and Instruction, Clemmer College, East Tennessee State University, 402 Warf-Pickel Hall, Johnson City, TN, 37614, USA.
| | - Jessica N Lester
- Department of Counseling and Educational Psychology, School of Education, 201 North Rose Avenue, Indiana University, Bloomington, IN, 47405-1006, USA.
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Marino F, Alby F, Zucchermaglio C, Scalisi TG, Lauriola M. Navigating Intercultural Medical Encounters: An Examination of Patient-Centered Communication Practices with Italian and Foreign Cancer Patients Living in Italy. Cancers (Basel) 2023; 15:cancers15113008. [PMID: 37296970 DOI: 10.3390/cancers15113008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
Effective communication is crucial in cancer care due to the sensitive nature of the information and the psychosocial impact on patients and their families. Patient-centered communication (PCC) is the gold standard for providing quality cancer care, as it improves patient satisfaction, treatment adherence, clinical outcomes, and overall quality of life. However, doctor-patient communication can be complicated by ethnic, linguistic, and cultural differences. This study employed the ONCode coding system to investigate PCC practices in oncological visits (doctor's communicative behavior, patient's initiatives, misalignments, interruptions, accountability, and expressions of trust in participants' talk, Markers of uncertainty in doctor's talk, markers of emotions in doctor's talk). Forty-two video-recorded patient-oncologist encounters (with 22 Italian and 20 foreign patients), including both first and follow-up visits, were analyzed. Three discriminant analyses were conducted to assess differences in PCC between patient groups (Italian or foreign patients) according to the type of encounter (first visit or follow-up) and the presence or absence of companions during the encounters. Multiple regression analyses were performed to evaluate the PCC differences by oncologist age, patient age, and patient sex, controlling for the type of encounter, the presence of a companion during the visit, and patient group on ONCode dimensions. No differences were found in PCC by patient group in discriminant analyses and regressions. Doctor communication behavior, interruptions, accountability, and expressions of trust were higher in first visits than in follow-ups. The disparities in PCC were primarily linked to the type of visit and the age of the oncologist. However, a qualitative analysis showed notable differences in the types of interruptions during visits with foreign patients compared to Italian patients. It is essential to minimize interruptions during intercultural encounters to foster a more respectful and conducive environment for patients. Furthermore, even when foreign patients demonstrate sufficient linguistic competence, healthcare providers should not solely rely on this factor to ensure effective communication and quality care.
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Affiliation(s)
- Filomena Marino
- Department of Social and Developmental Psychology, Sapienza Università di Roma, 00185 Roma, Italy
| | - Francesca Alby
- Department of Social and Developmental Psychology, Sapienza Università di Roma, 00185 Roma, Italy
| | - Cristina Zucchermaglio
- Department of Social and Developmental Psychology, Sapienza Università di Roma, 00185 Roma, Italy
| | - Teresa Gloria Scalisi
- Department of Social and Developmental Psychology, Sapienza Università di Roma, 00185 Roma, Italy
| | - Marco Lauriola
- Department of Social and Developmental Psychology, Sapienza Università di Roma, 00185 Roma, Italy
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Links AR, Callon W, Wasserman C, Beach MC, Ryan MA, Leu GR, Tunkel D, Boss EF. Treatment recommendations to parents during pediatric tonsillectomy consultations: A mixed methods analysis of surgeon language. PATIENT EDUCATION AND COUNSELING 2021; 104:1371-1379. [PMID: 33342578 DOI: 10.1016/j.pec.2020.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/19/2020] [Accepted: 11/11/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE A deeper understanding of the dialogue clinicians use to relay treatment recommendations is needed to fully understand their influence on patient decisions about surgery. We characterize how otolaryngologists provide treatment recommendations and suggest a classification framework. METHODS We qualitatively analyzed surgeon recommendations from 55 encounters between otolaryngologists and parents of children evaluated for tonsillectomy, and classified recommendation types by phrasing. Multilevel logistic regression identified predictors of recommendation phrasing. RESULTS Clinicians provided 183 recommendations (mean/visit = 3.3). We identified four domains of recommendation-phrasing (direct, passive, acceptable, parent-oriented). Direct recommendations (n = 68, 37%) included presumptive statements phrasing intentions as inevitable. Passive recommendations (n = 65, 36%) included practice-based recommendations utilizing general statements. Acceptable recommendations (n = 29, 16%) included speaking positively about treatment options. Parent-oriented recommendations (n = 21, 11%) included parent choice statements. Clinicians more commonly made direct recommendations to parents who were racial minorities (OR = 2.7, p = .02, 95% CI [1.7, 5.9]) or had an annual income <$50,000 (OR = 2.2, p = .03, 95% CI [1.1, 4.4]). CONCLUSION Clinicians provide treatment recommendations in a variety of ways that may introduce more or less certainty and choice to parental treatment decisions. PRACTICE IMPLICATIONS Findings may be implemented into training which increases clinician awareness of dialogue use when recommending treatment alternatives to patients.
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Affiliation(s)
- Anne R Links
- Johns Hopkins University School of Medicine, Department of Otolaryngology, Baltimore, USA.
| | - Wynne Callon
- Harvard Medical School, Boston Children's Hospital, Boston, USA
| | - Carly Wasserman
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, USA
| | - Mary Catherine Beach
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, USA
| | - Marisa A Ryan
- Johns Hopkins University School of Medicine, Department of Otolaryngology, Baltimore, USA
| | - Grace R Leu
- Johns Hopkins University School of Medicine, Department of Otolaryngology, Baltimore, USA
| | - David Tunkel
- Johns Hopkins University School of Medicine, Department of Otolaryngology, Baltimore, USA
| | - Emily F Boss
- Johns Hopkins University School of Medicine, Department of Otolaryngology, Baltimore, USA
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Sterponi L, Zucchermaglio C, Fantasia V, Fatigante M, Alby F. A room of one's own: Moments of mutual disengagement between doctor and patient in the oncology visit. PATIENT EDUCATION AND COUNSELING 2021; 104:1116-1124. [PMID: 33172737 DOI: 10.1016/j.pec.2020.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 09/22/2020] [Accepted: 10/16/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE This paper examines a previously neglected phenomenon in doctor-patient interaction studies, i.e. the achievement of mutual disengagement-a specific state of coordination, in which participants suspend reciprocal gaze and turn into separate axes of involvement. In the specialized setting of the oncology visit, which we consider in this study, mutual disengagement is linked to important tasks that the oncologist has to carry out, notably the scrutiny of the histological exam during the diagnostic assessment phase. METHODS Our data corpus includes 56 video-recorded oncology visits. We employ conversation analysis to discern how mutual disengagement is achieved, sustained and ended. RESULTS Our analysis shows that suspension of mutual engagement is a joint accomplishment that requires intersubjective cooperation. It also reveals that when talk and reciprocal engagement are suspended, intersubjective alignment is more vulnerable to breakdown. CONCLUSION Our findings eschew a characterization of the oncologist as solo arbiter of the interactional exchange. An alignment with the patient is key to the felicitous accomplishment of the visit. We also suggest that a successful medical encounter is not only characterized by harmonious verbal communication, between doctor and patient, but also by felicitous pauses in their joint engagement. PRACTICE IMPLICATIONS In building a room of one's own, the oncologist has the responsibility to co-construct with the patient an experience of interactional attunement and mutual understanding.
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Affiliation(s)
- Laura Sterponi
- University of California, Berkeley, Institute of Human Development and Graduate School of Education, 2121 Berkeley Way, Berkeley, CA, 94720, United States.
| | - Cristina Zucchermaglio
- University of Rome, La Sapienza, Department of Social and Developmental Psychology, Via dei Marsi 78, 00185, Rome, Italy
| | - Valentina Fantasia
- University of Rome, La Sapienza, Department of Social and Developmental Psychology, Via dei Marsi 78, 00185, Rome, Italy
| | - Marilena Fatigante
- University of Rome, La Sapienza, Department of Social and Developmental Psychology, Via dei Marsi 78, 00185, Rome, Italy
| | - Francesca Alby
- University of Rome, La Sapienza, Department of Social and Developmental Psychology, Via dei Marsi 78, 00185, Rome, Italy
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Fatigante M, Heritage J, Alby F, Zucchermaglio C. Presenting treatment options in breast cancer consultations: Advice and consent in Italian medical care. Soc Sci Med 2020; 266:113175. [PMID: 32987310 DOI: 10.1016/j.socscimed.2020.113175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/11/2020] [Accepted: 06/25/2020] [Indexed: 01/05/2023]
Abstract
Variety, complexity and uncertainty in the therapy outcomes of cancer illness make the treatment recommendation (TR) in oncology a "monumentally difficult task". Previous studies have distinguished unilateral and bilateral formats of treatment recommendations, accordingly to whether, or to what extent, the patient's perspective is included in the consideration of therapeutic options. Others have also shown how the oncologists' presentation of therapeutic options varied accordingly to the severity of the diagnosis and the availability of alternatives. Yet, no study has systemically dentified and compared components of treatment recommendation in oncology on a common set of patients and clinicians. This paper analyzes how different options in breast cancer treatments - radiotherapy, hormone therapy and chemotherapy - are presented and discussed in a set of 12 first post-surgical breast cancer visits carried out by two oncologists of high experience and seniority in two Italian hospitals. Treatment recommendation sequences involving these three option types were analyzed using the methods of conversation analysis. They were also coded for the mention of side effects and treatment burden, and for whether consent to the recommendation was invited, or expressed by the patient. Results show that radiotherapy is presented as presupposed as an extension of surgery and is not further discussed, and hormone therapy is delivered as good news and as not implying any health or lifestyle burdens. Treatment burdens were raised in the much more extensive discussions of chemotherapy, which were also accompanied by a higher chance that the patient was asked for consent to therapy. Implications are drawn as regards the extent to which clinical practice meets theory in communication protocols available in oncology, and how to consider the doctor-patient partnership and the concept of shared decision-making in such an encounter.
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Affiliation(s)
- Marilena Fatigante
- Department of Social and Developmental Psychology, University Sapienza of Rome, Rome, Italy.
| | - John Heritage
- Department of Sociology, University of California, Los Angeles, USA
| | - Francesca Alby
- Department of Social and Developmental Psychology, University Sapienza of Rome, Rome, Italy
| | - Cristina Zucchermaglio
- Department of Social and Developmental Psychology, University Sapienza of Rome, Rome, Italy
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Montali L, Benozzo A, Carlo Ripamonti S, Frigerio A, Galuppo L, Gemignani M, Vergine I. Qualitative research in social and organizational psychology: the Italian way. QUALITATIVE RESEARCH IN PSYCHOLOGY 2019. [DOI: 10.1080/14780887.2019.1605274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Lorenzo Montali
- Dipartimento di psicologia, Università degli Studi di Milano-Bicocca, Italy
| | - Angelo Benozzo
- Dipartimento di Scienze umane e sociali, Università della Valle D’Aosta, Italy
| | | | | | - Laura Galuppo
- Dipartimento di psicologia, Università Cattolica del Sacro Cuore di Milano, Italy
| | - Marco Gemignani
- Departamento de Psicología, Universidad Loyola Andalucía, Spain
| | - Ilaria Vergine
- Dipartimento di psicologia, Università Cattolica del Sacro Cuore di Milano, Italy
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Structuring times and activities in the oncology visit. Soc Sci Med 2019; 228:211-222. [DOI: 10.1016/j.socscimed.2019.03.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 03/17/2019] [Accepted: 03/21/2019] [Indexed: 11/19/2022]
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Caronia L, Saglietti M. Knowledge and agency in interprofessional care: How nurses contribute to the case-construction in an Intensive Care Unit. J Interprof Care 2018; 32:592-602. [DOI: 10.1080/13561820.2018.1463199] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Letizia Caronia
- Department of Education, School of Psychology and Science of Education, University of Bologna, Bologna, IT
| | - Marzia Saglietti
- Department of Education, School of Psychology and Science of Education, University of Bologna, Bologna, IT
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Alby F, Zucchermaglio C, Fatigante M. Communicating Uncertain News in Cancer Consultations. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2017; 32:858-864. [PMID: 27412563 DOI: 10.1007/s13187-016-1070-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
In cancer communication, most of the literature is in the realm of delivering bad news while much less attention has been given to the communication of uncertain news around the diagnosis and the possible outcomes of the illness. Drawing on video-recorded cancer consultations collected in two Italian hospitals, this article analyzes three communication practices used by oncologists to interactionally manage the uncertainty during the visit: alternating between uncertain bad news and certain good news, anticipating scenarios, and guessing test results. Both diagnostic and personal uncertainties are not hidden to the patient, yet they are reduced through these practices. Such communication practices are present in 32 % of the visits in the data set, indicating that the interactional management of uncertainty is a relevant phenomenon in oncological encounters. Further studies are needed to improve both its understanding and its teaching.
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Affiliation(s)
- Francesca Alby
- Department of Social and Developmental Psychology, Sapienza University of Rome, via dei Marsi, 78, 00185, Rome, Italy.
| | - Cristina Zucchermaglio
- Department of Social and Developmental Psychology, Sapienza University of Rome, via dei Marsi, 78, 00185, Rome, Italy
| | - Marilena Fatigante
- Department of Social and Developmental Psychology, Sapienza University of Rome, via dei Marsi, 78, 00185, Rome, Italy
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Alby F, Fatigante M, Zucchermaglio C. Managing risk and patient involvement in choosing treatment for cancer: an analysis of two communication practices. SOCIOLOGY OF HEALTH & ILLNESS 2017; 39:1427-1447. [PMID: 28833216 DOI: 10.1111/1467-9566.12598] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Drawing on conversation analyses of oncology consultations collected in Italy, the article examines the communication practices used to recommend treatments. We found that the oncologist formulates the treatment recommendation (TR) for high-risk patients in terms of a 'mandatory' choice and for low-risk patients as an 'optional' type of decision. In the first case the doctor presses to reach a decision during the visit while in the second case leaves the decision open-ended. Results show that high-risk patients have less time to decide, are pressured towards choosing an option, but have more opportunities for involvement in TR during the visit. Low-risk patients instead have more time and autonomy to make a choice, but they are also less involved in the decision-making in the visit time. Moreover, we document that TR is organised through sequential activities in which the oncologist informs the patient of alternative therapeutic options while at the same time building a case for the kind of treatment she/he believes to be best for the patient's health. We suggest that in this field risk plays a key role in decision-making which should be better understood with further studies and taken into account in the debate on shared decision-making and patient-centred communication.
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Affiliation(s)
- Francesca Alby
- Department of Developmental and Social Psychology, Sapienza University of Rome, Italy
| | - Marilena Fatigante
- Department of Developmental and Social Psychology, Sapienza University of Rome, Italy
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Landmark AMD, Svennevig J, Gerwing J, Gulbrandsen P. Patient involvement and language barriers: Problems of agreement or understanding? PATIENT EDUCATION AND COUNSELING 2017; 100:1092-1102. [PMID: 28065435 DOI: 10.1016/j.pec.2016.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 12/09/2016] [Accepted: 12/12/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE This study aims to explicate efforts for realizing patient-centeredness (PCC) and involvement (SDM) in a difficult decision-making situation. It investigates what communicative strategies a physician used and the immediate, observable consequences for patient participation. METHODS From a corpus of videotaped hospital encounters, one case in which the physician and patient used Norwegian as lingua franca was selected for analysis using conversation analysis (CA). Secondary data were measures of PCC and SDM. RESULTS Though the physician did extensive interactional work to secure the patient's understanding and acceptance of a treatment recommendation, his persistent attempts did not succeed in generating the patient's participation. In ratings of PCC and SDM, this case scored well above average. CONCLUSION Despite the fact that this encounter displays some of the 'best actual practice' of PCC and SDM within the corpus, our analysis of the interaction shows why the strategies were insufficient in the context of a language barrier and possible disagreement. PRACTICE IMPLICATIONS When facing problems of understanding, agreement and participation in treatment decision-making, relatively good patient centered skills may not suffice. Knowledge about the interactional realization of key activities is needed for developing training targeted at overcoming such challenges.
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Affiliation(s)
- Anne Marie Dalby Landmark
- MultiLing Center for Research on Multilingualism in Society across the Lifespan, Department of Linguistics and Scandinavian Studies, University of Oslo, Oslo, Norway; HØKH Health Services Research Centre, Akershus University Hospital, Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Jan Svennevig
- MultiLing Center for Research on Multilingualism in Society across the Lifespan, Department of Linguistics and Scandinavian Studies, University of Oslo, Oslo, Norway
| | - Jennifer Gerwing
- HØKH Health Services Research Centre, Akershus University Hospital, Lørenskog, Norway
| | - Pål Gulbrandsen
- HØKH Health Services Research Centre, Akershus University Hospital, Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Fasulo A, Pino M. Sharing knowledge and shaping identities in healthcare interactions. PATIENT EDUCATION AND COUNSELING 2016; 99:875-877. [PMID: 27316516 DOI: 10.1016/j.pec.2016.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
| | - Marco Pino
- University of Loughborough, Loughborough, UK
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Galatolo R, Margutti P. Territories of knowledge, professional identities and patients' participation in specialized visits with a team of practitioners. PATIENT EDUCATION AND COUNSELING 2016; 99:888-896. [PMID: 26778727 DOI: 10.1016/j.pec.2015.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 11/04/2015] [Accepted: 11/11/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE In specialized healthcare visits with a team of practitioners, the examination phase is a collaborative work where multiple professional competences are indexed and activated, contributing to a complex ecology of knowledge. The doctors' need to consult their colleagues might take over and collide with patients' understanding and willingness to participate. We describe the practices through which practitioners accomplish teamwork and how these impact on patients' participation. METHODS Using conversation analysis we investigate 30 video-recorded visits where patients with an injured upper limb meet a team of practitioners in an Italian centre for prosthesis construction and application. RESULTS Analysis shows the collaborative practices and division of labour through which practitioners activate their territories of knowledge in the service of the joint activity of evaluating the patient limbs' conditions. Whereas professionals orient to their different competences, patients keep their body available for inspection, monitor the ongoing activity, draw assumptions about their own conditions and tentatively claim their epistemic rights. CONCLUSIONS Doctors' orientation to teamwork involves the enactment of tacit communicative practices and the use of technical language, which might prevent or mislead patients' participation. PRACTICE IMPLICATIONS Doctors should employ communicative practices to ensure patients' understanding and participation in the unfolding examination activities.
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Affiliation(s)
- Renata Galatolo
- Department of Philosophy and Communication, University of Bologna, Bologna, Italy.
| | - Piera Margutti
- Department of Human and Social Sciences, University for Foreigners of Perugia, Perugia, Italy
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