How surgeons design treatment recommendations in orthopaedic surgery

How option-listing influences decision-making in orthopedic consultations: a conversation analytic study

OBJECTIVES

Examine which practices orthopedists use to do option-listing, a technique that can facilitate shared decision-making (SDM).

METHODS

A conversation analytic study of 35 orthopedic consultations with newly referred patients with hip and/or knee osteoarthritis.

RESULTS

Orthopedists implement option-listing in consultations using two organizational principles: 1) A fixed order of options that constitutes a scale (based on the severity of treatment). Presenting this scale (in two possible orders) encodes this fixed order; 2) Options are presented in relation to each other, rather than as individual options to be discussed incrementally. This format provides orthopedists with interactional slots to formulate their professional stance by presenting options as considered but rejected. Patients co-construct this list by taking a recipient role and not responding to the individual items of the list.

CONCLUSIONS

Option-listing can facilitate SDM, allowing patients to choose amongst options. A drawback is that, while the organizational principles of option-listing allow orthopedists to express a professional opinion, they also place patients in an interactional position in which they have to address the orthopedists' epistemic stance. On the other hand, patients can use the scale to propose their own preferences.

PRACTICAL IMPLICATIONS

Awareness of the interactional consequences of option-listing might optimize SDM.

Formulating cancer worries: How doctors establish medical expertise and authority to facilitate patients' care choices

Video recordings of oncology interviews reveal how doctors rely on worry to establish medical expertise, facilitate treatment decision-making, and construct worry parameters to help patients understand whether there is a reasonable need for worry or not. Doctors express worry as frequently as cancer patients during oncology interviews, but they face a dilemma: how to provide care for cancer patients without directly stating they are worried about them? Plausible explanations are offered for why doctors do not state personal worries. Conversation analytic methods were employed to identify how doctors rely on worry to achieve distinct social actions. Four worry formulations are examined: (1) variations of "we worry" (and at times, non-specific and second person "you"), (2) hypothetical worry scenarios, (3) dismissing worry and offering assurance, and (4) doctors claiming they are not worried, bothered, or alarmed. Doctors align with and speak for the professionals and institutions they represent, expressing collective worries and claiming the legitimate right to worry (or not). Doctors also avoid abandoning patients to their own decision-making, yet do not formulate worry to coerce deference or dictate patients' choices. In all cases patients agreed and displayed minimal resistance to doctors' worry formulations. These findings contribute to ongoing work across institutional settings where participants have been shown to construct objective, legitimate claims meriting worries about diverse problems. Work is underway to examine when and how patients explicitly raise and doctors respond to cancer worries. Clinical implications are raised for how doctors can use worry to legitimize best treatment options, help patients minimize their worries, rely on hypothetical scenarios allowing patients to compare how other patients managed their cancer, and not dismiss the importance of minimizing the need to worry as a resource for offering reassurance.

How a 'good parent' decides on childhood vaccination. Demonstrating independence and deliberation during Dutch healthcare visits

Childhood vaccination consultations are considered an important phase in parents' decision-making process. To date, only a few empirical studies conducted in the United States have investigated real-life consultations. To address this gap, we recorded Dutch vaccination conversations between healthcare providers and parents during routine health consultations for their newborns. The data were analysed using Conversation Analysis and Discursive Psychology. We found that the topic of vaccination was often initiated with 'Have you already thought about vaccination?' (HYATAV), and that this formulation was consequential for parental identity work. Exploring the interactional trajectories engendered by this initiation format we show that: (1) interlocutors treat the question as consisting of two types of queries, (2) conversational trajectories differ according to which of the queries is attended to and that (3) parents work up a 'good parent' identity in response to HYATAV, by demonstrating that they think about their child's vaccination beforehand and make their decisions independently. Our findings shed new light on the interactional unfolding of parental vaccination decisions.

Epistemic Trust as an Interactional Accomplishment in Pediatric Well-Child Visits: Parents' Resistance to Solicited Advice as Performing Epistemic Vigilance

Epistemic trust - i.e. the belief in knowledge claims we do not understand or cannot validate - is pivotal in healthcare interactions where trust in the source of knowledge is the foundation for adherence to therapy as well as general compliance with the physician's suggestions. However, in the contemporary knowledge society professionals can no longer count on unconditional epistemic trust: boundaries of the legitimacy and extension criteria of expertise have become increasingly fuzzier and professionals must take into account laypersons' expertise. Drawing on a conversation analysis-informed study of 23 videorecorded pediatrician-led well-child visits, the article deals with the communicative constitution of healthcare-relevant phenomena such as: epistemic and deontic struggles between parents and pediatricians, the local accomplishment of (responsible) epistemic trust, and the possible outcomes of blurred boundaries between the layperson's and the professional's "expertise." In particular, we illustrate how epistemic trust is communicatively built in sequences where parents request the pediatrician's advice and resist it. The analysis shows how parents perform epistemic vigilance by suspending the immediate acceptance of the pediatrician's advice in favor of inserting expansions that make it relevant for the pediatrician to account for her advice. Once the pediatrician has addressed parents' concerns, parents perform (delayed) acceptance, which we assume indexes what we call responsible epistemic trust. While acknowledging the advantages of what seems to be a cultural change in parent-healthcare provider encounters, in the conclusion we advance that possible risks are implied in contemporary fuzziness of the legitimacy and extension criteria of expertise in doctor-patient interaction.

Treatment recommendations to parents during pediatric tonsillectomy consultations: A mixed methods analysis of surgeon language

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.

Consent for spine surgery: an observational study

BACKGROUND

The tension between the ideal of informed consent and the reality of the process is under-investigated in spine surgery. Guidelines around consent imply a logical, plain-speaking process with a clear endpoint, agreement and signature yet surgeons' surveys and patient interviews suggest that surgeons' explanation is anecdotally variable and patient understanding remains poor. To obtain a more authentic reflection of practice, spine surgeons obtaining 'informed consent' for non-instrumented spine surgery were studied via video recording and risk/benefit discussions were analysed.

METHODS

A prospective observational study was conducted at a single neurosurgical institution. Twelve video recordings involving six surgeons obtaining an informed consent for non-instrumented spine surgery were transcribed verbatim and blindly analysed using descriptive quantification and linguistic ethnography.

RESULTS

Ten (83%) consultations discussed surgical benefit but less than half (41%) quantified the likelihood of benefit from surgery. The most discussed risks were nerve damage or paralysis (92%), bleeding (92%), infection (92%), cerebrospinal fluid leak (83%) and bowel and bladder dysfunction (75%). Surgeons commonly used a quantitative statement of risk (58%) but only half of the risks were explained in words patients were likely to understand.

CONCLUSIONS

This study highlights inconsistencies in the way spine surgeons explain risks and obtain informed consent for 'simple' spine procedures in a real-world setting. There are wide disparities in the provision of informed consent, which may be encountered in other surgical fields. Direct observation and qualitative analysis can provide insights into the limitations of current informed consent practice and help guide future practice.

Initiating end-of-life decisions with parents of infants receiving neonatal intensive care

OBJECTIVE

To investigate whether parent-initiated or doctor-initiated decisions about limiting life-sustaining treatment (LST) in neonatal care has consequences for how possible courses of action are presented.

METHOD

Formal conversations (n = 27) between doctors and parents of critically ill babies from two level 3 neonatal intensive care units were audio or video recorded. Sequences of talk where decisions about limiting LST were presented were analysed using Conversation Analysis and coded using a Conversation Analytic informed coding framework. Relationships between codes were analysed using Fisher's exact test.

RESULTS

When parents initiated the decision point, doctors subsequently tended to refer to or list available options. When doctors initiated, they tended to use 'recommendations' or 'single-option' choice (conditional) formats (p=0.017) that did not include multiple treatment options. Parent initiations overwhelmingly concerned withdrawal, as opposed to withholding of LST (p=0.030).

CONCLUSION

Aligning parents to the trajectory of the news about their baby's poor condition may influence how the doctor subsequently presents the decision to limit LST, and thereby the extent to which parents are invited to participate in shared decision-making.

PRACTICE IMPLICATIONS

Explicitly proposing treatment options may provide parents with opportunities to be involved in decisions for their critically ill babies, thereby fostering shared decision-making.

When and how do surgeons initiate noticings of additional concerns?

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.

'Breast cancer won't kill ya in the breast': Broaching a rationale for chemotherapy during the surgical consultation for early-stage breast cancer

OBJECTIVE

To examine how, and for what interactional purpose, a surgeon raises the risk of death with an early-stage breast cancer patient.

METHOD

Single-case analysis of a recorded surgical consultation, using conversation analysis.

RESULTS

The surgeon not only negotiates the surgical treatment decision with the patient, she provides an overview of what her non-surgical treatment is likely to entail. Analysis reveals how the surgeon addresses interactional challenges when providing this overview, including how to broach the rationale for administering chemotherapy, the possibility that cancer could spread to vital organs and prove fatal. To do this, the surgeon orients to the possibility that the patient has misconceptions about her risk of dying from breast cancer. She uses negatively-formulated assertions to invoke these possible misconceptions, making correction relevant and providing a point of entry into delicate interactional territory.

CONCLUSION

The surgeon draws upon possible patient misconceptions to broach the rationale for administering adjuvant chemotherapy.

PRACTICE IMPLICATIONS

The surgical consultation is typically the first treatment-related consultation newly-diagnosed breast cancer patients have and represents an opportunity to educate patients and prepare them for future treatment decisions. The challenges of providing and receiving such overviews, and how they may influence future treatment decisions, merit consideration.

Deferring the Decision Point: Treatment Assertions in Neurology Outpatient Consultations

Recommendations can be implied by asserting some generalisation about a treatment's benefit without overtly directing the patient to take it. Focusing on a collection of assertions in UK neurology consultations, this paper shows that these are overwhelmingly receipted as "merely" doing informing and argues that this is made possible by their ambiguous design: their relatively depersonalised formats convey that the neurologist is simply telling the patient what's available, but the link made between the treatment and the patient's condition implies that it will be of benefit. Thus, assertions, while stopping short of telling the patient what to do, are hearable as recommendation relevant. This delicates balance leaves it up to the patient to respond either to the implied or on-record action (recommending vs. informing). When treated as "merely" doing informing, assertions defer the decision point until the neurologist has done something more. Three main interactional functions of this are identified as follows: (i) indicating the existence of a solution to a concern, without making a decision relevant next; (ii) orienting to the patient's right to choose; and (iii) making "cautious" recommendations.

Treatment Recommendation Actions, Contingencies, and Responses: An Introduction

In the era of patient participation in health care decision making, we know surprisingly little about the ways in which treatment recommendations are made, the contexts that shape their formulation, and the consequences of these formulations. In this article, we introduce a systematic collective investigation of how recommendations for medications are responded to and made in primary versus secondary care, in the US versus the UK, and in contexts where the medication was over the counter versus by prescription. This article provides an overview of the coding system that was used in this project including describing what constitutes a recommendation, the primary action types clinicians use for recommendations, and the types of responses provided by patients to recommendations.

How Psychiatrists Recommend Treatment and Its Relationship with Patient Uptake

Consultations for patients with chronic mental health conditions are conceived as meetings of experts: medical and experiential, respectively. Treatment decisions, in these terms, become a joint responsibility rather than handed down ex-cathedra. One resource for constituting decisions as 'shared' is the treatment recommendation - decisional authority can be invoked through its design. There is concern that people diagnosed with schizophrenia are infrequently involved in treatment decisions. However, the methods psychiatrists actually employ remain undefined. This article advances our understanding of psychiatric practice by mapping alternative methods used by psychiatrists to recommend treatment in outpatient consultations in situ. First, we unpack the types of treatments psychiatrists recommend. Then, we ask how psychiatrists recommend treatment? Applying a novel coding taxonomy, informed by the conversation analytic principle that recommendations represent different social actions, we identify the distribution of alternative formulations for psychiatrists' recommendations (pronouncements, suggestions, proposals, and offers). We also propose one linguistic dimension, personal pronouns, on which recommending actions often depend, implicative for who is projected as 'accountable' for the decision. Finally, we examine the relationship between action type and patient uptake: is a particular type of recommendation more likely to attract acceptance/resistance from patients? And how does this relate to decisional accountability?

Evaluating nuanced practices for initiating decision-making in neurology clinics: a mixed-methods study

Background

We report follow-on research from our previous qualitative analysis of how neurologists offer patients choice in practice. This focus reflects the NHS’s emphasis on ‘patient choice’ and the lack of evidence-based guidance on how to enact it. Our primary study identified practices for offering choice, which we called ‘patient view elicitors’ (PVEs) and ‘option-listing’. However, that study was not designed to compare these with recommendations or to analyse the consequences of selecting one practice over another.

Objectives

To (1) map out (a) the three decision-making practices – recommending, PVEs and option-listing – together with (b) their interactional consequences; (2) identify, qualitatively and quantitatively, interactional patterns across our data set; (3) statistically examine the relationship between interactional practices and self-report data; and (4) use the findings from 1–3 to compare the three practices as methods for initiating decision-making.

Design

A mixed-methods secondary analysis of recorded neurology consultations and associated questionnaire responses. We coded every recommendation, PVE and option-list together with a range of variables internal (e.g. patients’ responses) and external to the consultation (e.g. self-reported patient satisfaction). The resulting matrix captured the qualitative and quantitative data for every decision.

Setting and participants

The primary study was conducted in two neurology outpatient centres. A total of 14 neurologists, 223 patients and 114 accompanying others participated.

Results

Distribution of practices – recommending was the most common approach to decision-making. Patient demographics did not appear to play a key role in patterning decisional practices. Several clinical factors did show associations with practice, including (1) that neurologists were more likely to use option-lists or PVEs when making treatment rather than investigation decisions, (2) they were more certain about a diagnosis and (3) symptoms were medically explained. Consequences of practices – option-lists and PVEs (compared with recommendations) – were strongly associated with choice by neurologists and patients. However, there was no significant difference in overall patient satisfaction relating to practices employed. Recommendations were strongly associated with a course of action being agreed. Decisions containing PVEs were more likely to end in rejection. Option-lists often ended in the decision being deferred. There was no relationship between length of consultation and the practice employed.

Limitations

A main limitation is that we judged only outcomes based on the recorded consultations and the self-report data collected immediately thereafter. We do not know what happened beyond the consultation.

Conclusions

Patient choice is harder to enact than policy directives acknowledge. Although there is good evidence that neurologists are seeking to enact patient choice, they are still more likely to make recommendations. This appears to be partly due to concerns that ‘choice’ might conflict with doctors’ duty of care. Future guidance needs to draw on evidence regarding choice in practice to support doctors and patients to achieve the wider goal of shared decision-making.

Future research

To advance understanding of how interactional practices might have effects beyond the clinic, a priority is to investigate associations between decision-making practices and external outcomes (such as adherence).

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Generating the perception of choice: the remarkable malleability of option-listing

The normative view that patients should be offered more choice both within and beyond the UK's National Health Service (NHS) has been increasingly endorsed. However, there is very little research on whether - and how - this is enacted in practice. Based on 223 recordings of neurology outpatient consultations and participants' subsequent self-reports, this article shows that 'option-listing' is a key practice for generating the perception of choice. The evidence is two-fold: first, we show that neurologists and patients overwhelmingly reported that choice was offered in those consultations where option-listing was used; second, we demonstrate how option-listing can be seen, in the interaction itself, to create a moment of choice for the patient. Surprisingly, however, we found that even when the patient resisted making the choice or the neurologist adapted the practice of option-listing in ways that sought acceptance of the neurologist's own recommendation, participants still agreed that a choice had been offered. There was only one exception: despite the use of option-listing, the patient reported having no choice, whereas the neurologist reported having offered a choice. We explore this deviant case in order to shed light on the limits of option-listing as a mechanism for generating the perception of choice.

Conversation Analysis of Veterinarians' Proposals for Long-Term Dietary Change in Companion Animal Practice in Ontario, Canada

Nutritional changes recommended by veterinarians to clients can have a major role in animal-patient health. Although there is literature on best practices that can inform veterinary communication training, little is known specifically about how veterinarians communicate their recommendations to clients in real-life interactions. This study used the qualitative research method of conversation analysis to investigate the form and content of veterinarian-initiated proposals for long-term dietary change in canine and feline patients to further inform veterinary communication training. We analyzed the characteristics and design of veterinarian-initiated proposals for long-term nutritional modification as well as the appointment phases during which they occurred, in a subsample of 42 videotaped segments drawn from 35 companion animal appointments in eastern Ontario, Canada. Analyses indicated that veterinarians initiated proposals at various points during the consultations rather than as a predictable part of treatment planning at the end. While some proposals were worded strongly (e.g., "She should be on…"), most proposals avoided the presumption that dietary change would inevitably occur. Such proposals described dietary items as options (e.g., "There are also special diets…") or used mitigating language (e.g., "you may want to try…"). These findings seem to reflect delicate veterinarian-client dynamics associated with dietary advice-giving in veterinary medicine that can impact adherence and limit shared decision-making. Our analyses offer guidance for communication training in veterinary education related to dietary treatment decision-making.

Managing risk and patient involvement in choosing treatment for cancer: an analysis of two communication practices

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.

Patient involvement and language barriers: Problems of agreement or understanding?

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.

Communication practices that encourage and constrain shared decision making in health-care encounters: Systematic review of conversation analytic research

Background

Shared decision making (SDM) is generally treated as good practice in health‐care interactions. Conversation analytic research has yielded detailed findings about decision making in health‐care encounters.

Objective

To map decision making communication practices relevant to health‐care outcomes in face‐to‐face interactions yielded by prior conversation analyses, and to examine their function in relation to SDM.

Search strategy

We searched nine electronic databases (last search November 2016) and our own and other academics' collections.

Inclusion criteria

Published conversation analyses (no restriction on publication dates) using recordings of health‐care encounters in English where the patient (and/or companion) was present and where the data and analysis focused on health/illness‐related decision making.

Data extraction and synthesis

We extracted study characteristics, aims, findings relating to communication practices, how these functioned in relation to SDM, and internal/external validity issues. We synthesised findings aggregatively.

Results

Twenty‐eight publications met the inclusion criteria. We sorted findings into 13 types of communication practices and organized these in relation to four elements of decision‐making sequences: (i) broaching decision making; (ii) putting forward a course of action; (iii) committing or not (to the action put forward); and (iv) HCPs' responses to patients' resistance or withholding of commitment. Patients have limited opportunities to influence decision making. HCPs' practices may constrain or encourage this participation.

Conclusions

Patients, companions and HCPs together treat and undertake decision making as shared, though to varying degrees. Even for non‐negotiable treatment trajectories, the spirit of SDM can be invoked through practices that encourage participation (eg by bringing the patient towards shared understanding of the decision's rationale).

Healthcare professionals' assertions and women's responses during labour: A conversation analytic study of data from One born every minute

OBJECTIVE

Communication during labour is consequential for women's experience yet analyses of situated labour-ward interaction are rare. This study demonstrates the value of explicating the interactional practices used to initiate 'decisions' during labour.

METHODS

Interactions between 26 labouring women, their birth partners and HCPs were transcribed from the British television programme, One Born Every Minute. Conversation analysis was used to examine how decisions were initiated and accomplished in interaction.

FINDINGS

HCPs initiate decision-making using interactional practices that vary the 'optionality' afforded labouring women in the responsive turn. Our focus here is on the minimisation of optionality through 'assertions'. An 'assertive' turn-design (e.g. 'we need to…') conveys strong expectation of agreement. HCPs assert decisions in contexts of risk but also in contexts of routine activities. Labouring women tend to acquiesce to assertions.

CONCLUSION

The expectation of agreement set up by an assertive initiating turn can reduce women's opportunities to participate in shared decision-making (SDM).

PRACTICE IMPLICATIONS

When decisions are asserted by HCPs there is a possible dissonance between the tenets of SDM in British health policy and what occurs in situ. This highlights an educational need for HCPs in how best to afford labouring women more optionality, particularly in low-risk contexts.

Treatment Availability Influences Physicians' Portrayal of Robotic Surgery During Clinical Appointments

In order to empower patients as decision makers, physicians must educate them about their treatment options in a factual, nonbiased manner. We propose that site-specific availability of treatment options may be a novel source of bias, whereby physicians describe treatments more positively when they are available. We performed a content analysis of physicians' descriptions of robotic prostatectomy within 252 appointments at four Veterans Affairs medical centers where robotic surgery was either available or unavailable. We coded how physicians portrayed robotic versus open prostatectomy across specific clinical categories and in the appointment overall. We found that physicians were more likely to describe robotic prostatectomy as superior when it was available [F(1, 42) = 8.65, p = .005]. We also provide initial qualitative evidence that physicians may be shaping their descriptions of robotic prostatectomy in an effort to manage patients' emotions and demand for the robotic technology. To our knowledge, this is the first study to provide empirical evidence that treatment availability influences how physicians describe the advantages and disadvantages of treatment alternatives to patients during clinical encounters, which has important practical implications for patient empowerment and patient satisfaction.

‘What Brings Him Here Today?’: Medical Problem Presentation Involving Children with Autism Spectrum Disorders and Typically Developing Children

Conversation and discourse analyses were used to examine medical problem presentation in pediatric care.Healthcare visits involving children with ASD and typically developing children were analyzed. We examined how children’s communicative and epistemic capabilities, and their opportunities to be socialized into a competent patient role are interactionally achieved. We found that medical problem presentation is designed to contain a ‘pre-visit’ account of the interactional and epistemic work that children and caregivers carry out at home to identify the child’s health problems; and that the intersubjective accessibility of children’s experiences that becomes disrupted by ASD presents a dilemma to all participants in the visit. The article examines interactional roots of unmet healthcare needs and foregone medical care of people with ASD.

Formulating treatment recommendation as a logical consequence of the diagnosis in post-surgical oncological visits

OBJECTIVE

the article analyzes how a doctor delivers diagnoses and recommends treatment in a set of post-surgical oncological visits. The pattern of activities are explored in two different cases: when all diagnostic information is available, and when information is still missing.

METHODS

The data consist of 12 video-recorded visits of breast cancer patients to a senior oncologist. Conversation analysis is employed to analyze sequences in which the delivery of diagnosis and treatment recommendation unfold.

RESULTS

The oncologist formulates the treatment recommendation as a logical consequence deriving from the available diagnostic information. In cases when definitive diagnostic information on the cancer type is missing, the oncologist opts to anticipate hypothetical diagnostic scenarios, and to draw the therapeutic alternatives as logical outcomes envisionable from each of the different scenarios.

CONCLUSION

The communicative practice appears functional to encourage the patients' acceptance of a single treatment option rather than present the patients to and involve them in deliberating over multiple available treatment alternatives.

PRACTICE IMPLICATIONS

Rather than a normative adoption of existing protocols of communication in cancer care, a better understanding of communication practices in use can help practitioners to reflect upon and make intentional choices about different arrangements for the patient's participation.

Justifying medication decisions in mental health care: Psychiatrists' accounts for treatment recommendations

Psychiatric practitioners are currently encouraged to adopt a patient centered approach that emphasizes the sharing of decisions with their clients, yet recent research suggests that fully collaborative decision making is rarely actualized in practice. This paper uses the methodology of Conversation Analysis to examine how psychiatrists justify their psychiatric treatment recommendations to clients. The analysis is based on audio-recordings of interactions between clients with severe mental illnesses (such as, schizophrenia, bipolar disorders, etc.) in a long-term, outpatient intensive community treatment program and their psychiatrist. Our focus is on how practitioners design their accounts (or rationales) for recommending for or against changes in medication type and dosage and the interactional deployment of these accounts. We find that psychiatrists use two different types of accounts: they tailor their recommendations to the clients' concerns and needs (client-attentive accounts) and ground their recommendations in their professional expertise (authority-based accounts). Even though psychiatrists have the institutional mandate to prescribe medications, we show how the use of accounts displays psychiatrists' orientation to building consensus with clients in achieving medical decisions by balancing medical authority with the sensitivity to the treatment relationship.

Delivering patient choice in clinical practice: a conversation analytic study of communication practices used in neurology clinics to involve patients in decision-making

Background

The NHS is committed to offering patients more choice. Yet even within the NHS, the meaning of patient choice ranges from legal ‘rights to choose’ to the ambition of establishing clinical practice as a ‘partnership’ between doctor and patient. In the absence of detailed guidance, we focused on preciselyhowto engage patients in decision-making.

Objectives

To contribute to the evidence-base about whether or not, and how, patient choice is implemented to identify the most effective communication practices for facilitating patient choice.

Design

We used conversation analysis to examine practices whereby neurologists offer choice. The main data set consists of audio- and video-recorded consultations. Patients completed pre- and post-consultation questionnaires and neurologists completed the latter.

Setting and participants

The study was conducted in neurology outpatient clinics in Glasgow and Sheffield. Fourteen neurologists, 223 patients and 120 accompanying others took part.

Results

Patients and clinicians agreed that choice had featured in 53.6% of consultations and that choice was absent in 14.3%. After 32.1% of consultations,eitherpatientorneurologist thought choice was offered. The presence or absence of choice was not satisfactorily explained by quantitatively explored clinical or demographic variables. For our qualitative analysis, the corpus was divided into four subsets: (1) patient and clinician agree that choice was present; (2) patient and clinician agree that choice was absent; (3) patient ‘yes’, clinician ‘no’; and (4) patient ‘no’, clinician ‘yes’. Comparison of all subsets showed that ‘option-listing’ was the only practice for offering choice that was presentonly(with one exception, which, as we show, proves the rule) in those consultations for which participantsagreed there was a choice. We show how option-listing can be used to engage patients in decision-making, but also how very small changes in the machinery of option-listing [for instance the replacement or displacement of the final component of this practice, the patient view elicitor (PVE)] can significantly alter the slot for patient participation. In fact, a slightly modified form of option-listing can be used to curtail choice. Finally, we describe two forms of PVE that can be used to hand a single-option decision to the patient, but which, we show, can raise difficulties for patient choice.

Conclusions

Choice features in the majority of recorded consultations. If doctors want to ensure a patient knows she or he has a choice, option-listing is likely to be best understood by patients as an invitation to choose. However, an important lesson from this study is that simply asking doctors to adopt a practice (like option-listing) will not automatically lead to a patient-centred approach. Our study shows that preciselyhowa practice is implemented is crucial.

Future research

Future research should investigate (1) links between the practices identified here and relevant outcome measures (like adherence); (2) whether being given a choice is better or worse for patients than receiving a doctor’s recommendation, taking account of clinical and demographic factors; and (3) how our approach could be fruitfully applied in other settings.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Physician communication styles in initial consultations for hematological cancer

OBJECTIVE

To characterize practices in subspecialist physicians' communication styles, and their potential effects on shared decision-making, in second-opinion consultations.

METHODS

Theme-oriented discourse analysis of 20 second-opinion consultations with subspecialist hematologist-oncologists.

RESULTS

Physicians frequently "broadcasted" information about the disease, treatment options, relevant research, and prognostic information in extended, often-uninterrupted monologs. Their communicative styles had one of two implications: conveying options without offering specific recommendations, or recommending one without incorporating patients' goals and values into the decision. Some physicians, however, used techniques that encouraged patient participation.

CONCLUSIONS

Broadcasting may be a suboptimal method of conveying complex treatment information in order to support shared decision-making. Interventions could teach techniques that encourage patient participation.

PRACTICE IMPLICATIONS

Techniques such as open-ended questions, affirmations of patients' expressions, and pauses to check for patient understanding can mitigate the effects of broadcasting and could be used to promote shared decision-making in information-dense subspecialist consultations.

Initiating decision-making in neurology consultations: 'recommending' versus 'option-listing' and the implications for medical authority

This article compares two practices for initiating treatment decision-making, evident in audio-recorded consultations between a neurologist and 13 patients in two hospital clinics in the UK. We call these 'recommending' and 'option-listing'. The former entails making a proposal to do something; the latter entails the construction of a list of options. Using conversation analysis (CA), we illustrate each, showing that the distinction between these two practices matters to participants. Our analysis centres on two distinctions between the practices: epistemic differences and differences in the slots each creates for the patient's response. Considering the implications of our findings for understanding medical authority, we argue that option-listing - relative to recommending - is a practice whereby clinicians work to relinquish a little of their authority. This article contributes, then, to a growing body of CA work that offers a more nuanced, tempered account of medical authority than is typically portrayed in the sociological literature. We argue that future CA studies should map out the range of ways - in addition to recommending - in which treatment decision-making is initiated by clinicians. This will allow for further evidence-based contributions to debates on the related concepts of patient participation, choice, shared decision-making and medical authority.

How do patients with end-stage ankle arthritis decide between two surgical treatments? A qualitative study

OBJECTIVE

To examine how patients decide between ankle fusion and ankle replacement in end-stage ankle arthritis.

DESIGN

Purposive patient selection, semistructured interviews, thematic analysis.

SETTING

Royal National Orthopaedic Hospital, Stanmore, UK.

PARTICIPANTS

14 patients diagnosed with end-stage ankle osteoarthritis.

RESULTS

We interviewed 6 men and 8 women with a mean age of 58 years (range 41-83). All had opted for surgery after failure of at least 6 months of conservative management, sequentially trading-off daily activities to limit the evolving pain. To decide between two offered treatments of ankle fusion and total ankle replacement (TAR), three major sources informed the patients' decision-making process: their surgeon, peers and the internet. The treating surgeon was viewed as the most reliable and influential source of information. Information gleaned from other patients was also important, but with questionable reliability, as was information from the internet, both of which invariably required validation by the surgeon and in some cases the general practitioner.

CONCLUSIONS

Patients seek knowledge from a wealth of sources including the internet, web forums and other patients. While they leverage each of these sources to guide decision-making, the most important and influential factor in governing how patients decide on any particular surgical intervention is their surgeon. A high quality doctor-patient relationship, coupled with clear, balanced and complete information is essential to enable shared decision-making to become a standard model of care.

The omni-relevance of surgery: how medical specialization shapes orthopedic surgeons' treatment recommendations

This article examines treatment recommendations in orthopedic surgery consultations and shows how surgery is treated as "omni-relevant" within this activity, providing a context within which the broad range of treatment recommendations proposed by surgeons is offered. Using conversation analysis to analyse audiotaped encounters between orthopedic surgeons and patients, we highlight how surgeons treat surgery as having a special, privileged status relative to other treatment options by (1) invoking surgery (whether or not it is actually being recommended) and (2) presenting surgery as the "last best resort" (in relation to which other treatment options are calibrated, described and considered). This privileged status surfaces in the design and delivery of recommendations as a clear asymmetry: Recommendations for surgery are proposed early, in relatively simple and unmitigated form. In contrast, recommendations not for surgery tend to be delayed and involve significantly more interactional work in their delivery. Possible implications of these findings, including how surgeons' structuring of recommendations may shape patient expectations (whether for surgery or some alternative), and potentially influence the distribution of orthopedic surgery procedures arising from these consultations, are considered.