Asymmetrical knowledge claims in general practice consultations with frequently attending patients: Limitations and opportunities for patient participation

Switching Clinics: Patient Autonomy over the Course of Their Careers in Consumer Medicine

Patient autonomy, or the right to make decisions about medical care, is usually examined either within clinical encounters with medical providers or outside of clinics via social movements to transform care. These perspectives, however, may miss how patients exercise autonomy outside of clinical encounters while remaining in conventional care. Through in-depth interviews with 61 people who pursued fertility treatment in New York City, this article argues that one important way that people exert autonomy in consumer medicine is by switching clinics. This study finds that nearly half of participants switched clinics to reorient their patient careers that were not progressing satisfactorily, attempting to reset, redirect, and escalate them. This article emphasizes that patients exercise autonomy not just over treatment decisions but also over the direction and progress of patient careers themselves. This article suggests that patients' disparate opportunities to elect to switch medical practices represents an inequity in consumer medicine.

'It feels like my metabolism has shut down'. Negotiating interactional roles and epistemic positions in a primary care consultation

INTRODUCTION

Our aim is to explore the ways in which a patient and a general practitioner (GP) negotiate knowledge claims stemming from different epistemic domains while dealing with a mismatch between experiential and biomedical knowledge during the clinical consultation. We interpret their interaction in relation to the sociocultural context in which their negotiation is embedded and identify factors facilitating their successful negotiation (a medical error is avoided).

METHODS

Based on a narrative analysis of a verbatim transcript of a complete naturally occurring primary care consultation, we explore the moment-to-moment unfolding of talk between the patient and the GP (two women).

FINDINGS

The patient experiences symptoms of what she interprets as a thyroid condition, and indirectly asks for medication. She presents her case by drawing on experiential knowledge ('it feels like my metabolism has shut down') and biomedical knowledge (while suggesting a diagnosis and a diagnostic test). The GP informs her that her thyroid blood tests are normal and uses biomedical knowledge to explain why she turns down the patient's request. This stages a potential conflict between the patient's embodied experiential knowledge and the doctor's biomedical knowledge. However, during their encounter, the patient and the GP manage to co-construct the patient's illness story and make shared decisions about further actions.

CONCLUSION

The transition from potential conflict to consensus is a result of the mutual efforts of two parties: a patient who persistently claims experiential as well as biomedical knowledge while at the same time deferring to the GP's professional knowledge, and a GP who maintains her epistemic authority while also acknowledging the patient's experiential and biomedical knowledge.

PATIENT AND PUBLIC CONTRIBUTION

Our empirical data are sourced from a data archive and patients were not involved in the design or conduct of the study, but our study is based on a naturally occurring clinical consultation with a patient.

The Basic Science of Patient-Physician Communication: A Critical Scoping Review

PURPOSE

Strong verbal communication skills are essential for physicians. Despite a wealth of medical education research exploring communication skills training, learners struggle to become strong communicators. Integrating basic science into the curriculum provides students with conceptual knowledge that improves learning outcomes and facilitates the development of adaptive expertise, but the conceptual knowledge, or "basic science," of patient-provider communication is currently unknown. This review sought to address that gap and identify conceptual knowledge that would support improved communication skills training for medical trainees.

METHOD

Combining the search methodology of Arksey and O'Malley with a critical analytical lens, the authors conducted a critical scoping review of literature in linguistics, cognitive psychology, and communications to determine: what is known about verbal communication at the level of word choice in physician-patient interactions? Studies were independently screened by 3 researchers during 2 rounds of review. Data extraction focused on theoretical contributions associated with language use and variation. Analysis linked patterns of language use to broader theoretical constructs across disciplines.

RESULTS

The initial search returned 15,851 unique studies, and 271 studies were included in the review. The dominant conceptual groupings reflected in the results were: (1) clear and explicit language, (2) patient participation and activation, (3) negotiating epistemic knowledge, (4) affiliative language and emotional bonds, (5) role and identity, and (6) managing transactional and relational goals.

CONCLUSIONS

This in-depth exploration supports and contextualizes theory-driven research of physician-patient communication. The findings may be used to support future communications research in this field and educational innovations based on a solid theoretical foundation.

Communicating with older adults with long-term conditions about self-management goals: A systematic review and thematic synthesis

OBJECTIVE

To synthesise a body of fine-grained observational research on communication between healthcare professionals (HCPs), older adults, and carers regarding self-management goals and actions.

METHODS

We conducted a systematic review, searching nine electronic databases and the grey literature. Two reviewers independently selected for inclusion following a two-stage process and studies and discrepancies were resolved through consultation with the review team.

RESULTS

898 records were retrieved, and eight studies were included in the review. Aggregative thematic analysis resulted in 13 categories of communication practices across three decision-making domains: (1) initiating: actions occurring prior to the commitment point; (2) proposing: putting forward a course of action; and (3) committing and closing: committing (or not) to the course of action.

CONCLUSIONS

Despite an increasing emphasis on the importance of personalised care planning and shared decision-making (SDM) to support older people's health and wellbeing, HCPs did not consistently practice this approach and, in some cases, worked in opposition to it.

PRACTICE IMPLICATIONS

We encourage HCPs to prepare older adults to engage actively with SDM and the goal setting process by employing patient-centred communication resources. These could assist with identifying different types of goals that are realistic and relevant to patients in daily life.

Negotiating bodily sensations between patients and GPs in the context of standardized cancer patient pathways - an observational study in primary care

BACKGROUND

How interactions during patient-provider encounters in Swedish primary care construct access to further care is rarely explored. This is especially relevant nowadays since Standardized Cancer Patient Pathways have been implemented as an organizational tool for standardizing the diagnostic process and increase equity in access. Most patients with symptoms indicating serious illness as cancer initially start their diagnostic trajectory in primary care. Furthermore, cancer symptoms are diverse and puts high demands on general practitioners (GPs). Hence, we aim to explore how presentation of bodily sensations were constructed and legitimized in primary care encounters within the context of Standardized Cancer Patient Pathways (CPPs).

METHODS

Participant observations of patient-provider encounters (n = 18, on 18 unique patients and 13 GPs) were carried out at primary healthcare centres in one county in northern Sweden. Participants were consecutively sampled and inclusion criteria were i) patients (≥18 years) seeking care for sensations/symptoms that could indicate cancer, or had worries about cancer, Swedish speaking and with no cognitive disabilities, and ii) GPs who met with these patients during the encounter. A constructivist approach of grounded theory method guided the data collection and was used as a method for analysis, and the COREQ-checklist for qualitative studies (Equator guidelines) were employed.

RESULTS

One conceptual model emerged from the analysis, consisting of one core category Negotiating bodily sensations to legitimize access, and four categories i) Justifying care-seeking, ii) Transmitting credibility, iii) Seeking and giving recognition, and iv) Balancing expectations with needs. We interpret the four categories as social processes that the patient and GP constructed interactively using different strategies to negotiate. Combined, these four processes illuminate how access was legitimized by negotiating bodily sensations.

CONCLUSIONS

Patients and GPs seem to be mutually dependent on each other and both patients' expertise and GPs' medical expertise need to be reconciled during the encounter. The four social processes reported in this study acknowledge the challenging task which both patients and primary healthcare face. Namely, negotiating sensations signaling possible cancer and further identifying and matching them with the best pathway for investigations corresponding as well to patients' needs as to standardized routines as CPPs.

Following the algorithm: How epidemiological risk-scores do accountability

Epidemiological risk scores are calculative devices that mediate and enact versions of accountability in public health and preventive medicine. This article focuses on practices of accountability by following a cardiovascular risk score widely used in medical counselling in Germany. We follow the risk score in the making, in action, and in circulation to explore how the score performs in doctor-patient relations, how it recombines epidemiological results, and how it shapes knowledge production and healthcare provision. In this way, we follow the risk score's various trajectories - from its development at the intersection of epidemiology, general medicine and software engineering, to its usage in general practitioners' offices, and its validation infrastructures. Exploring the translations from population to individual and back that are at work in the risk score and in the primary prevention of cardiovascular disease, we examine how versions and distributions of accountability are invoked and practiced as the score is developed and put to use. The case of a simple risk score used in everyday counselling brings into relief some key shifts in configurations of accountability with emerging versions of 'health by the algorithm'. While there is an increasing authority of algorithmic tools in the fabric of clinical encounters, risk scores are interwoven with local specificities of the healthcare system and continue to be in the making.

Six principles to enhance health workforce flexibility

This paper proposes approaches to break down the boundaries that reduce the ability of the health workforce to respond to population needs, or workforce flexibility. Accessible health services require sufficient numbers and types of skilled workers to meet population needs. However, there are several reasons that the health workforce cannot or does not meet population needs. These primarily stem from workforce shortages. However, the health workforce can also be prevented from responding appropriately and efficiently because of restrictions imposed by professional boundaries, funding models or therapeutic partitions. These boundaries limit the ability of practitioners to effectively diagnose and treat patients by restricting access to specific skills, technologies and services. In some cases, these boundaries not only reduce workforce flexibility, but they introduce inefficiencies in the form of additional clinical transactions and costs, further detracting from workforce responsiveness. Several new models of care are being developed to enhance workforce flexibility by enabling existing staff to work to their full scope of practice, extend their roles or by introducing new workers. Expanding on these concepts, this theoretical paper proposes six principles that have the potential to enhance health workforce flexibility, specifically: 1. Measure health system performance from the perspective of the patient. 2. Minimise training times. 3. Regulate tasks (competencies), not professions. 4. Match rewards and indemnity to the levels of skill and risk required to perform a particular task, not professional title. 5. Ensure that practitioners have all the skills they need to perform the tasks required to work in the environment in which they work 6. Enable practitioners to work to their full scope of practice delegate tasks where required These proposed principles will challenge some of the existing social norms around health-care delivery; however, many of these principles are already being applied, albeit on a small scale. This paper discusses the implications of these reforms.

PROPOSED DISCUSSION POINTS

1. Is person-centred care at odds with professional monopolies? 2. Should the state regulate professions and, by doing so, protect professional monopolies or, instead, regulate tasks or competencies? 3. Can health-care efficiency be enhanced by reducing the number of clinical transactions required to meet patient needs?

Do gender differences affect the doctor-patient interaction during consultations in general practice? Results from the INTERMEDE study

OBJECTIVE

The aim of the study was to ascertain whether disagreement between GPs and patients on advice given on nutrition, exercise and weight loss is related to patient-doctor gender discordance. Our hypothesis is that a patient interacting with a physician of the same gender may perceive more social proximity, notably on health care beliefs and may be more inclined to trust them.

METHODS

The analysis used the Intermede project's quantitative data collected via mirrored questionnaires at the end of the consultation. Multilevel logistic regressions were carried out to explore associations between patient-doctor gender discordance and their disagreement on advice given during the consultation adjusted on patients' and physicians' characteristics. The sample consists of 585 eligible patients and 27 GPs.

RESULTS

Disagreement on advice given on nutrition was observed less often for female concordant dyads: OR = 0.25 (95% CI = 0.08-0.78), and for female doctors-male patients dyads: OR = 0.24 (95% CI = 0.07-0.84), taking the male concordant dyads as reference. For advice given on exercise, disagreement was found less often for female concordant dyads OR = 0.38 (95% CI = 0.15-0.98) and an interdoctor effect was found (P < 0.05). For advice given on weight loss, the probability of disagreement was significantly increased (OR: 2.87 95% CI = 1.29-6.41) when consultations consisted of female patient and male GP.

CONCLUSION

Patient-doctor gender concordance/discordance is associated with their agreement/disagreement on advice given during the consultation. Physicians need to be conscious that their own demographic characteristics and perceptions might influence the quality of prevention counseling delivered to their patients.

Displays of authority in the clinical consultation: a linguistic ethnographic study of the electronic patient record

The introduction of computers into general practice settings has profoundly changed the dynamics of the clinical consultation. Previous research exploring the impact of the computer (in what has been termed the 'triadic' consultation) has shown that computer use and communication between doctor and patient are intricately coordinated and inseparable. Swinglehurst et al. have recently been critical of the ongoing tendency within health communication research to focus on 'the computer' as a relatively simple 'black box', or as a material presence in the consultation. By re-focussing on the electronic patient record (EPR) and conceptualising this as a complex collection of silent but consequential voices, they have opened up new and more nuanced possibilities for analysis. This orientation makes visible a tension between the immediate contingencies of the interaction as it unfolds moment-by-moment and the more standardised, institutional demands which are embedded in the EPR ('dilemma of attention'). In this paper I extend this work, presenting an in-depth examination of how participants in the consultation manage this tension. I used linguistic ethnographic methods to study 54 video recorded consultations from a dataset collected between 2007 and 2008 in two UK general practices, combining microanalysis of the consultation with ethnographic attention to the wider organisational and institutional context. My analysis draws on the theoretical work of Erving Goffman and Mikhail Bakhtin, incorporating attention to the 'here and now' of the interaction as well as an appreciation of the 'distributed' nature of the EPR, its role in hosting and circulating new voices, and in mediating participants' talk and social practices. It reveals - in apparently fleeting moments of negotiation and contestation - the extent to which the EPR shapes the dynamic construction, display and circulation of authority in the contemporary consultation.

Does argumentation matter? A systematic literature review on the role of argumentation in doctor-patient communication

In view of a growing interest in argumentative discourse in the context of patient-centered consultation and shared decision making, this article explores the role that argumentation has been attributed in the literature on doctor-patient consultation so far. It studies to what extent theories and concepts of argumentation have been applied by scholars from various fields in order to analyze, understand, facilitate, and improve the argumentative nature of medical consultation. It reports on an extensive and systematic literature search-using eight online databases, expert suggestions, and a manual search-and the subsequent evaluation of 1,330 abstracts on the basis of strict inclusion and exclusion criteria. Forty relevant scientific contributions are grouped into four main categories and discussed accordingly: (a) argumentation theory, (b) discourse analysis, (c) medical informatics, and (d) medical ethics. Because of its systematic approach, this study forms a solid starting point for further integration of argumentation theoretical insights into contemporary views of patient-centered medicine and evidence-based medicine. It provides suggestions for further interdisciplinary and theory-driven research with a strong focus on empirical reality. Doing so, a preliminary model is proposed that outlines the potential effects of the quality of doctors' communication on proximal, intermediate, and long-term consultation outcomes.

Hedging, knowledge and interaction: Doctors' and clients' talk about medical information and client experiences in genetic counseling

OBJECTIVES

The article starts from the observation that professionals in genetic counseling deploy the strategy of 'hedging'. It shows how hedging is used in a particular sequential position: doctors' responses to clients' presentations of personal information during information delivery sequences.

METHODS

The data consist of video-recorded sessions of genetic counseling. The methodology is based on ethnomethodological conversation analysis. The analysis identifies interactional patterns in the counseling sessions.

RESULTS

In their responses doctors display an orientation to different access to different kinds of knowledge. In particular, the doctors tread carefully when commenting on the situation of a particular client vis-á-vis the symptoms and prognosis of genetic conditions. Furthermore, the article shows that the doctors' responses and hedging devices in them are fitted to the form and function of the clients' presentations of personal experience.

CONCLUSION

While the focus of the article is narrow in that it concentrates on one type of an interactional sequence, its strength is that it shows how the doctor's talk can be intertwined with the client's contributions.

PRACTICE IMPLICATIONS

The results make it possible for genetic counselors to identify an interactional task they recurrently face and reflect on alternative ways of responding to it.

Is perceived social distance between the patient and the general practitioner related to their disagreement on patient's health status?

OBJECTIVE

To ascertain whether disagreement between patients and general practitioners (GP) on the patient's health status varies according to their respective perceived social distance (PSD).

METHODS

The analysis used the Intermede project's quantitative data collected from 585 patients and 27 doctors via mirrored questionnaires. GPs and patients ranked their own perceived social position (PSP) in society, and their patients' and their GP respectively. PSD was calculated as the PSP's subtraction from the patients' and GPs' assessments.

RESULTS

Disagreement between GPs and patients regarding the patient's health status was associated with PSD by the GP whereas it was not associated with PSD by the patient. In the multilevel analysis, disagreement whereby GPs overestimate patient's health status increased within PSD by the GP: OR:2.9 (95%CI = 1.0-8.6, p = 0.055) for low PSD, OR:3.4 (95%CI = 1.1-10.2, p < 0.05) for moderate PSD and OR:3.8 (95%CI = 1.1-13.1, p < 0.05) for high PSD (reference: no distance).

CONCLUSIONS

Patients perceived with a lower social position by their GP and who consider themselves to have poor health are less likely to be identified in the primary care system.

PRACTICE IMPLICATIONS

Physicians need to be conscious that their own perception influences the quality of the interaction with their patients, potentially resulting in unequal health care trajectories.

Do general practitioners overestimate the health of their patients with lower education?

This study sought to ascertain whether disagreement between patients and physicians on the patients' health status varies according to patients' education level. INTERMEDE is a cross-sectional multicentre study. Data were collected from both patients and doctors via pre- and post consultation questionnaires at the GP's office over a two-week period in October 2007 in 3 regions of France. The sample consists of 585 eligible patients (61% women) and 27 GPs. A significant association between agreement/disagreement between GP and patient on the patient's health status and patient's education level was observed: 75% of patients with a high education level agreed with their GP compared to 50% of patients with a low level of education. Patients and GPs disagreed where patients with the lowest education level said that their health was worse relative to their doctor's evaluation 37% of the time, versus 16% and 14% for those with a medium or high education level respectively. A multilevel multivariate analysis revealed that patients with a low educational level and medium educational level respectively were at higher risk of being overestimated by GP's in respect of self-reported health even if controlling for confounders. These findings suggest that people with a lower education level who consider themselves to have poor health are less reliably identified as such in the primary care system. This could potentially result in lack of advice and treatment for these patients and ultimately the maintenance of health inequalities.