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Sinnott C, Ansari A, Price E, Fisher R, Beech J, Alderwick H, Dixon-Woods M. Understanding access to general practice through the lens of candidacy: a critical review of the literature. Br J Gen Pract 2024; 74:e683-e694. [PMID: 38936884 PMCID: PMC11441605 DOI: 10.3399/bjgp.2024.0033] [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: 01/17/2024] [Accepted: 05/13/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Dominant conceptualisations of access to health care are limited, framed in terms of speed and supply. The Candidacy Framework offers a more comprehensive approach, identifying diverse influences on how access is accomplished. AIM To characterise how the Candidacy Framework can explain access to general practice - an increasingly fraught area of public debate and policy. DESIGN AND SETTING Qualitative review guided by the principles of critical interpretive synthesis. METHOD We conducted a literature review using an author-led approach, involving iterative analytically guided searches. Articles were eligible for inclusion if they related to the context of general practice, without geographical or time limitations. Key themes relating to access to general practice were extracted and synthesised using the Candidacy Framework. RESULTS A total of 229 articles were included in the final synthesis. The seven features identified in the original Candidacy Framework are highly salient to general practice. Using the lens of candidacy demonstrates that access to general practice is subject to multiple influences that are highly dynamic, contingent, and subject to constant negotiation. These influences are socioeconomically and institutionally patterned, creating risks to access for some groups. This analysis enables understanding of the barriers to access that may exist, even though general practice in the UK is free at the point of care, but also demonstrates that a Candidacy Framework specific to this setting is needed. CONCLUSION The Candidacy Framework has considerable value as a way of understanding access to general practice, offering new insights for policy and practice. The original framework would benefit from further customisation for the distinctive setting of general practice.
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Affiliation(s)
- Carol Sinnott
- Health Foundation professor of healthcare improvement studies, The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge
| | - Akbar Ansari
- Health Foundation professor of healthcare improvement studies, The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge
| | - Evleen Price
- Health Foundation professor of healthcare improvement studies, The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge
| | | | | | | | - Mary Dixon-Woods
- Health Foundation professor of healthcare improvement studies, The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge
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Barnes RK, Woods CJ. Communication in Primary Healthcare: A State-of-the-Art Literature Review of Conversation-Analytic Research. RESEARCH ON LANGUAGE AND SOCIAL INTERACTION 2024; 57:7-37. [PMID: 38707494 PMCID: PMC11067862 DOI: 10.1080/08351813.2024.2305038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
We report the first state-of-the-art review of conversation-analytic (CA) research on communication in primary healthcare. We conducted a systematic search across multiple bibliographic databases and specialist sources and employed backward and forward citation tracking. We included 177 empirical studies spanning four decades of research and 16 different countries/health systems, with data in 17 languages. The majority of studies originated in United States and United Kingdom and focused on medical visits between physicians and adult patients. We generated three broad research themes in order to synthesize the study findings: managing agendas, managing participation, and managing authority. We characterize the state-of-the-art for each theme, illustrating the progression of the work and making comparisons across different languages and health systems, where possible. We consider practical applications of the findings, reflect on the state of current knowledge, and suggest some directions for future research. Data reported are in multiple languages.
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Affiliation(s)
- Rebecca K. Barnes
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, U.K.
| | - Catherine J. Woods
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, U.K.
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Dicks C, Rogers SN, Kanatas A, Lowe D, McHale C, Humphris G. Concerns raised by people treated for head and neck cancer: a secondary analysis of audiotaped consultations in a health services follow-up clinic. Support Care Cancer 2023; 31:608. [PMID: 37792118 PMCID: PMC10550852 DOI: 10.1007/s00520-023-08059-w] [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: 05/20/2023] [Accepted: 09/21/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE People treated for head and neck cancer (HNC) face various barriers in communicating concerns with consultants. Our aim was to investigate the number of concerns raised between patients using the Patient Concerns Inventory (PCI) and those who did not. The PCI is a 57-item prompt list used in routine HNC follow-up clinics. Additionally, we aimed to examine whether who initiated the concerns differed between groups and the factors that may predict this initiation. METHODS Secondary data analysis included 67 participants across 15 HNC consultants from specialist cancer centres in Liverpool and Leeds. Seven consultants utilised the PCI and eight did not, assigned by preferential and random assignment. RESULTS Patients in the PCI group raised on average 2.5 more concerns than patients in the non-PCI group (p < .001). There was no significant relationship between group and who initiated the first concern (p = .28). A mixed-effects logistic regression was found to significantly predict who initiated the first concern in consultations (p < .05). DISCUSSION The number of concerns raised by patients increased when the PCI was introduced pre-HNC consultation. A number of factors were shown to predict the number of concerns raised in consultations by both patient and consultant. As concerns may not be raised further following the concern mentioned, we propose that the discussion of concerns needs to be maintained by the clinician throughout the consultation and not solely at the start. CONCLUSION The PCI promoted the sharing of concerns in follow-up consultations between patient and consultant.
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Affiliation(s)
- Corrie Dicks
- Division of Population and Behavioural Sciences, Medical School, University of St Andrews, St Andrews, KY16 9TF UK
| | - Simon N. Rogers
- Evidence-Based Practice Research Centre (EPRC), Faculty of Health and Social Care, Edge Hill University, St Helens Road, Ormskirk, L39 4QP UK
- Maxillofacial Department, Wirral University Teaching Hospital, Arrowe Park, CH49 5PE UK
| | - Anastasios Kanatas
- Leeds Teaching Hospitals and St James Institute of Oncology, Leeds Dental Institute and Leeds General Infirmary, Leeds, UK
| | - Derek Lowe
- Astraglobe Ltd., 24 Trinity Place, Mossley, Congleton, Cheshire, CW12 3JB UK
| | - Calum McHale
- Division of Population and Behavioural Sciences, Medical School, University of St Andrews, St Andrews, KY16 9TF UK
| | - Gerry Humphris
- Division of Population and Behavioural Sciences, Medical School, University of St Andrews, St Andrews, KY16 9TF UK
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Allgood S, Park J, Soleiman K, Saha S, Han D, McArthur A, Moore RD, Beach MC. Taxonomy and effectiveness of clinician agenda-setting questions in routine ambulatory encounters: A mixed method study. PATIENT EDUCATION AND COUNSELING 2023; 115:107889. [PMID: 37480792 DOI: 10.1016/j.pec.2023.107889] [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: 02/01/2023] [Revised: 06/28/2023] [Accepted: 07/06/2023] [Indexed: 07/24/2023]
Abstract
OBJECTIVES Despite decades of communication training, studies repeatedly demonstrate that clinicians fail to elicit patients' agendas. Our goal was to provide clinicians with actionable guidance about the effectiveness of agenda-soliciting questions. METHODS We coded clinician agenda-soliciting questions and patient responses in audio-recorded ambulatory encounters at an urban academic hospital. To evaluate the association between question type and odds of the patient raising a concern, we performed mixed-effects logistic regression. RESULTS We identified 346 agenda-soliciting questions within 138 visits (mean 2.51/visit; range 0-9). Agenda-soliciting questions were categorized as personal state inquiries (37%, "How are you?"), feeling-focused (5% "How're you feeling?"), problem-focused (12%; "Are you having any problems"), direct solicitations (3%; "Anything you want to discuss today?"), "what else" (3%), "anything else" (14%), leading (16%; "Nothing else today?"), and space-reducing (11% "Anything else? Smoking?"). Patients raised a concern in response to 107 clinician questions (27%). Patients were more likely to raise a concern to direct solicitation (OR 22.95, 95% CI 2.62-200.70) or "what else" (OR 4.68, 95% CI 1.05-20.77) questions. CONCLUSIONS The most effective agenda-soliciting questions are used least frequently by clinicians. PRACTICE IMPLICATIONS Clinicians should elicit patient agendas by using direct language, and solicit additional concerns using "what else" vs. "anything else" questions.
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Affiliation(s)
| | - Jenny Park
- Oregon Health & Science University, Portland, OR, USA
| | | | | | - Dingfen Han
- Johns Hopkins University, Baltimore, MD, USA
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Vennik J, Hughes S, Smith KA, Misurya P, Bostock J, Howick J, Mallen C, Little P, Ratnapalan M, Lyness E, Dambha-Miller H, Morrison L, Leydon G, Everitt H, Bishop FL. Patient and practitioner priorities and concerns about primary healthcare interactions for osteoarthritis: A meta-ethnography. PATIENT EDUCATION AND COUNSELING 2022; 105:1865-1877. [PMID: 35125208 DOI: 10.1016/j.pec.2022.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 11/10/2021] [Accepted: 01/21/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To explore primary care practitioners' (PCPs) and patients' priorities and concerns for healthcare interactions for osteoarthritis (OA) in primary care. METHODS We searched Embase, CINAHL, Medline, PsychInfo (1990 to present) for primary qualitative and mixed methods studies with findings concerning healthcare interactions for OA symptoms. Patient and PCP perceptions were analysed separately then inter-related using a 'line of argument' synthesis. RESULTS Twenty-six studies reporting qualitative data from 557 patients and 199 PCPs were synthesised. Our findings suggest that therapeutic interactions for OA can be based on discordant priorities and concerns; some patients perceive that PCPs hold negative attitudes about OA and feel their concerns about impact are not appreciated; some PCPs feel patients have misconceptions about prognosis, and hold pessimistic views about outcomes; and both tend to de-prioritise OA within consultations. CONCLUSION Greater working in partnership could build mutual trust, facilitate tailored provision of information, and foster a shared understanding of OA upon which to build realistic goals for management. PRACTICE IMPLICATIONS Developing a better shared understanding of OA has the potential to improve the quality of healthcare interactions for both patients and PCPs. The significant impact of OA on everyday life means it should be given higher priority in primary care consultations.
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Affiliation(s)
- Jane Vennik
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK.
| | - Stephanie Hughes
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Kirsten A Smith
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Pranati Misurya
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | | | - Jeremy Howick
- Faculty of Philosophy, University of Oxford, Oxford, UK
| | - Christian Mallen
- School of Primary, Community and Social Care, Keele University, Keele, UK
| | - Paul Little
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Mohana Ratnapalan
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Emily Lyness
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Hajira Dambha-Miller
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Leanne Morrison
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Geraldine Leydon
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Hazel Everitt
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Felicity L Bishop
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
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Drossman DA, Chang L, Deutsch JK, Ford AC, Halpert A, Kroenke K, Nurko S, Ruddy J, Snyder J, Sperber A. A Review of the Evidence and Recommendations on Communication Skills and the Patient-Provider Relationship: A Rome Foundation Working Team Report. Gastroenterology 2021; 161:1670-1688.e7. [PMID: 34331912 DOI: 10.1053/j.gastro.2021.07.037] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/12/2021] [Accepted: 07/19/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Over several decades, changes in health care have negatively impacted meaningful communication between the patient and provider and adversely affected their relationship. Under increasing time pressure, physicians rely more on technology than face-to-face time gathering data to make clinical decisions. As a result, they find it more challenging to understand the illness context and fully address patient needs. Patients experience dissatisfaction and a diminution of their role in the care process. For patients with disorders of gut-brain interaction, stigma leads to greater care dissatisfaction, as there is no apparent structural basis to legitimize the symptoms. Recent evidence suggests that practical communication skills can improve the patient-provider relationship (PPR) and clinical outcomes, but these data are limited. METHODS The Rome Foundation convened a multidisciplinary working team to review the scientific evidence with the following aims: a) to study the effect of communication skills on patient satisfaction and outcomes by performing an evidence-based review; b) to characterize the influence of sociocultural factors, health care system constraints, patient perspective, and telehealth on the PPR; c) to review the measurement and impact of communication skills training on these outcomes; and d) to make recommendations to improve communication skills training and the PPR. RESULTS Evidence supports the fact that interventions targeting patient-provider interactions improve population health, patient and provider experience, and costs. Communication skills training leads to improved patient satisfaction and outcomes. The following are relevant factors to consider in establishing an effective PPR: addressing health care system constraints; incorporating sociocultural factors and the role of gender, age, and chronic illness; and considering the changing role of telehealth on the PPR. CONCLUSIONS We concluded that effective communication skills can improve the PPR and health outcomes. This is an achievable goal through training and system change. More research is needed to confirm these findings.
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Affiliation(s)
- Douglas A Drossman
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Center for Education and Practice of Biopsychosocial Care, Drossman Gastroenterology, and the Rome Foundation, Chapel Hill, North Carolina.
| | - Lin Chang
- Vatche and Tamar Manoukian Division of Digestive Diseases, G. Opopenbhemer Center for Neurobiology of Stress and Resilience, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, Calfornia
| | - Jill K Deutsch
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, Connecticut
| | - Alexander C Ford
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK; Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
| | - Albena Halpert
- Gastroenterology,Harvard University Health Services, Boston, Massachusetts
| | - Kurt Kroenke
- Regenstrief Institute, Indiana University School of Medicine, Indianapolis, Indiana
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - Johannah Ruddy
- Center for Education and Practice of Biopsychosocial Care and Rome Foundation, Raleigh, North Carolina
| | - Julie Snyder
- Gastrointetinal Psychology Service, Boston University, Harvard Medical School, Boston, Massachusetts
| | - Ami Sperber
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Rathod S, Graves E, Kingdon D, Thorne K, Naeem F, Phiri P. Cultural Adaptations in Clinical InteractiONs (CoACtION): a multi-site comparative study to assess what cultural adaptations are made by clinicians in different settings. Int Rev Psychiatry 2021; 33:3-15. [PMID: 32368938 DOI: 10.1080/09540261.2020.1750818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Culture influences models of mental illness, help-seeking behaviours and outcomes of interventions. Cultural competency training has been developed to improve clinician practice in addressing these issues. The study aims to identify to what extent culturally competent and informed interactions are used by clinicians in England and how patients experience these interaction. Clinicians and non-white western patients were recruited to complete a questionnaire on culturally adapted practice in 25 areas of England. Clinicians are much more likely to rate their practice as clinically competent whereas patients were more likely to disagree that services were completely culturally competent. Length of time working as clinicians, receipt of specific cultural competence training and a higher percentage of caseload from non-white western backgrounds all increased clinician's perception that their practice was culturally competent. Clinicians recognised the importance of cultural competency but the disparity between their assessment of whether they achieved this and that of patients must be addressed. Ethics approval was obtained via proportionate review from the London - Central Research Ethics Committee (REC Ref no: 17/LO/1962). Study registration: UK Clinical Research Network Portfolio: 36744.
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Affiliation(s)
| | | | - David Kingdon
- Department of Medicine, University of Southampton, Southampton, UK
| | | | - Farooq Naeem
- Centre for Addiction & Mental Health, University of Toronto, Toronto, ON, Canada
| | - Peter Phiri
- Southern Health NHS Foundation Trust, Southampton, UK
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Artioli G, Foà C, Cosentino C, Taffurelli C, Sarli L. The Patient's Narrative Agenda as an assessment tool: the story of Robert, suffering from osteosarcoma. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:7-15. [PMID: 32168307 PMCID: PMC7944659 DOI: 10.23750/abm.v91i2-s.9371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Indexed: 12/04/2022]
Abstract
Background and aim of the work. To activate the participation of the person in his/her care path, the literature highlights the impact of the professional’s ability to show a genuine interest in the problems brought by the patient and to recognize him/her as ‘competent’. In this sense the narrative patient’s agenda could be a useful relational tool, because is focused on the perception of patient experiences of his/her illness. Thus this study aims to analyze the usefulness of patient’s narrative agenda during the assessment phase. Method. A semi-structured interview has been adopted to explore the agenda of Robert, 21 years old, suffering from osteosarcoma. A first level analysis identified the four functional areas of the agenda: ideas and beliefs; expectations and desires and context in which he lives and interacts. A second level analysis assessed the main Robert’s problems. Results. The narrative agenda has highlighted many central problems of Robert (e.g. therapeutic adherence, quality of life, mood, body image, existential problems related to experiences, hopes and expectations). Of course these results could be integrated with other tools: qualitative, to Understand difficulties and to formulate hypotheses, and quantitative, to measure the level of severity of problems reported. Discussion and conclusion. The narrative agenda has not only proved to be a valid instrument of assessment, allowing an adequate insight on the patient’s problems, as we exemplified, but it can be also used for monitoring the dynamic situation of the person’s history, lending itself to the re-exploration of its functional areas over time.
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Affiliation(s)
| | - Chiara Foà
- Department of Medicine and Surgery, University of Parma, Italy.
| | | | | | - Leopoldo Sarli
- Department of Medicine and Surgery, University of Parma, Italy.
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Amelung D, Whitaker KL, Lennard D, Ogden M, Sheringham J, Zhou Y, Walter FM, Singh H, Vincent C, Black G. Influence of doctor-patient conversations on behaviours of patients presenting to primary care with new or persistent symptoms: a video observation study. BMJ Qual Saf 2020; 29:198-208. [PMID: 31326946 PMCID: PMC7057803 DOI: 10.1136/bmjqs-2019-009485] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/02/2019] [Accepted: 07/09/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Most cancers are diagnosed following contact with primary care. Patients diagnosed with cancer often see their doctor multiple times with potentially relevant symptoms before being referred to see a specialist, suggesting missed opportunities during doctor-patient conversations. OBJECTIVE To understand doctor-patient communication around the significance of persistent or new presenting problems and its potential impact on timely cancer diagnosis. RESEARCH DESIGN Qualitative thematic analysis based on video recordings of doctor-patient consultations in primary care and follow-up interviews with patients and doctors. 80 video observations, 20 patient interviews and 7 doctor interviews across 7 general practices in England. RESULTS We found that timeliness of diagnosis may be adversely affected if doctors and patients do not come to an agreement about the presenting problem's significance. 'Disagreements' may involve misaligned cognitive factors such as differences in medical knowledge between doctor and patient or misaligned emotional factors such as patients' unexpressed fear of diagnostic procedures. Interviews suggested that conversations where the difference in views is either not recognised or stays unresolved may lead to unhelpful patient behaviour after the consultation (eg, non-attendance at specialist appointments), creating potential for diagnostic delay and patient harm. CONCLUSIONS Our findings highlight how doctor-patient consultations can impact timely diagnosis when patients present with persistent or new problems. Misalignments were common and could go unnoticed, leaving gaps for potential to cause patient harm. These findings have implications for timely diagnosis of cancer and other serious disease because they highlight the complexity and fluidity of the consultation and the subsequent impact on the diagnostic process.
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Affiliation(s)
| | | | - Debby Lennard
- Public Involvement Programme (People in Research), National Institute for Health and Care Excellence, London, UK
| | - Margaret Ogden
- Public Involvement Programme (People in Research), National Institute for Health and Care Excellence, London, UK
| | - Jessica Sheringham
- Department of Applied Health Research, University College London, London, UK
| | - Yin Zhou
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Fiona M Walter
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | | | - Georgia Black
- Department of Applied Health Research, University College London, London, UK
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White AEC. When and how do surgeons initiate noticings of additional concerns? Soc Sci Med 2019; 244:112320. [PMID: 31493926 DOI: 10.1016/j.socscimed.2019.05.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 05/10/2019] [Accepted: 05/16/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Physicians are trained on how to best solicit additional concerns from patients. What has not yet been studied is when and how physicians initiate additional concerns. This analysis focuses on when and how general surgeons share their noticings of medical problems unrelated to the upcoming (or recent) procedures that patients are being seen for. METHODS 281 video-recorded medical encounters with 95 patients from a rural Texas (USA) general surgery private practice were reviewed for surgeon noticings of additional concerns. In addition to analyzing the videos using Conversation Analysis, the author conducted 9 months of ethnographic research to gain understanding of the local setting. RESULTS 22 cases of surgeon noticings were found in 17 visits and were typically detected during the physical examination. Surgeons shared noticings adjacent to their discovery and predominantly framed noticings as bad news tellings. This framing helped mitigate 4 dilemmas surgeons encountered: unknown patient awareness of concern, surgeons' rights to assess areas unrelated to upcoming (or recent) procedures, not meeting the desired health optimization outcome & putting additional burden on patients, and other contextual factors specific to the visit that make sharing a noticing difficult. In addition to alerting patients and potentially activating earlier treatment, sharing noticings can also function to help build physician-patient relationships across time and curtail future patient worry. IMPLICATIONS Each surgeon noticing is potentially a concern that may have otherwise remained undetected and untreated, and speaks to the importance of physicians taking time to conduct thorough physical examinations.
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