Dueling in the clinic: When patients and providers disagree about healthcare recommendations

Dialogued into being: Constructing knowledge about hand osteoarthritis from a polyphony of voices in healthcare encounters

PURPOSE

Multiple knowledge sources inform healthcare. In healthcare encounters, patients and health professionals' ideas intersect to understand illness and disease. Exploring what is thought of as legitimate knowledge, and where those reflections come from is central to the process of improving and developing healthcare. Within this context, we aim to explore how knowledge about hand osteoarthritis (OA) is constructed and negotiated in clinical consultations.

METHODOLOGY

The article is based on interviews with 21 patients and 14 health professionals in combination with observation in 16 clinical consultations. Reflexive thematic analysis was used to interpret the data.

RESULTS

We generated four themes from codes to tell an interpretive story about how hand OA meaning-making is "talked into being" in patient-provider encounters: from the dominant voice of health professionals, from patients as knowers in the chronic healthcare dialogue, from health professionals and patients constructing knowledge together and from the construction of knowledge in hybrid positions when patients are health professionals and health professionals have hand OA.

CONCLUSION

New knowledge about hand OA is co-constructed in the situated context of the clinical encounter through a polyphony of voices-some of which are dominant, while others occupy the periphery-within and between the interactants in dialgue.

Pharmaceuticalization and Care Coordination in New York City Outpatient Mental Health

US government quality measures prioritize pharmaceuticalization and care coordination to promote patient treatment adherence. How these measures affect outpatient mental health service delivery and patient-provider communication where psychiatrists and nonphysicians collaborate is understudied. Analyzing 500 hours of participant-observation, 117 appointments, and 98 interviews with 45 new patients and providers, I show that psychiatrists and social workers coordinated care by encouraging medications and seeing two mental health providers as the default treatment, irrespective of patient preferences. Ethnographic perspectives crucially account for models of service delivery and provider behaviors in researching treatment adherence.

"Doing being a good parent" in the pediatric clinic: Parents' knowledge displays in advice requests on infants' everyday care

Parents and pediatricians play pivotal roles in promoting a nurturing environment for children's growth and development, especially during the critical first thousand days of life. Given the challenges involved in infant care and rearing, parents often rely on pediatricians' professional support in a wide range of daily caregiving practices as diverse as complementary feeding, hygiene management, pacifier use, or sleep routines. Nevertheless, little attention has been devoted to the in vivo observation of how parents actually request advice on babies' everyday care, and how pediatricians attend to such requests. By adopting a conversation analysis approach to a corpus of 23 videorecorded Italian pediatric well-child visits, the article explores the different ways through which parents navigate the face-threatening activity of soliciting the pediatrician's advice on infants' everyday care and management. The analysis illustrates that parents overall display (different degrees of) prior knowledge and competence on the topics brought to the pediatrician's attention while, at the same time, acknowledging the pediatrician's expertise and professional role. In this way, I argue that parents display themselves as competent, knowledgeable, caring, and therefore "good parents". After discussing the results, in the concluding remarks I point to what seems to be a cultural change in parent-healthcare provider interactions.

High-Stakes Treatment Negotiations Gone Awry: The Importance of Interactions for Understanding Treatment Advocacy and Patient Resistance

Doctors (and sociologists) have a long history of struggling to understand why patients seek medical help yet resist treatment recommendations. Explanations for resistance have pointed to macrostructural changes, such as the rise of the engaged patient or decline of physician authority. Rather than assuming that concepts such as resistance, authority, or engagement are exogenous phenomena transmitted via conversational conduits, we examine how they are dynamically co-constituted interactionally. Using conversation analysis to analyze a videotaped interaction of an oncology patient resisting the treatment recommendation even though she might die without treatment, we show how sustained resistance manifests in and through her doctor's actions. This paradox, in which the doctor can both recommend life-prolonging care and condition resistance to it, has broad relevance beyond cancer treatment; it also can help us to understand other doctor-patient decisional conflicts, for instance, medication nonadherence, delaying emergent care, and vaccine refusal.

How student healthcare providers in a communication skills course respond to standardized patient resistance

Encountering and responding to patient resistance can be especially challenging for student healthcare providers. Navigating who ultimately holds the authority to know and understand a health concern, make recommendations for a course of action, and accept or resist these recommendations are all part of how epistemic authority is negotiated in medical settings. The purpose of this paper is to systematically examine how student providers enrolled in a communication skills course at an American university responded to standardized patient resistance. The data for this study were 121 video-recorded and transcribed final objective structured clinical examinations from the fall 2019 course. We used discourse analysis informed by principles of conversation analysis to identify several discursive strategies used by the students, including: 1) asking for clarification; 2) expressing uncertainty and offering to gather additional resources; 3) aligning with and offering an account for the resistance; 4) recommending a new course of action; and 5) confronting the resistance. Our findings point to the value of including instruction for both student healthcare providers and standardized patients on how to respond to resistance they encounter in ways that may help improve healthcare outcomes.

Negative consequences of self-presentation on disclosure of health information: A catch-22 for Black patients?

RATIONALE

Most patients assume that it is adaptive to present oneself in a positive light when interacting with medical professionals. Here in two studies focused on Black patients we ask: might this desire to present oneself well inhibit the disclosure of health-relevant information when patients are concerned about negative and stereotypic evaluations by their health care providers?

OBJECTIVE

Specifically, we explore three important questions: First, whether self-presentational efforts (e.g., working hard to sound knowledgeable or "smart") are negatively associated with disclosure of health information (e.g., not taking certain medications); Second, whether patient-provider racial congruence (e.g. Black patients interacting with a Black vs. a White doctor) moderates that relationship; and third, more broadly, what factors promote or inhibit disclosure of health information for Black patients in medical interactions.

METHODS

These questions were investigated using mixed methodology (survey, experimental, qualitative) studies on CloudResearch and Prolific.

RESULTS

We found a potential catch-22: participants who spend more effort self-presenting tend to be less comfortable disclosing health information to their healthcare providers. Moreover, Study 1 (N = 321) indicated that the negative relationship between self-presentation and disclosure was significant in Black-incongruent (i.e., Black patient and White provider) and White-congruent (i.e., White patient and White provider) medical interactions. Study 2 (N = 361) did not find a significant moderation by race of the provider but instead suggested that the relationship between self-presentation and disclosure was moderated by expectations of unfair treatment. Exploratory qualitative analyses suggested that some Black participants face a dilemma when deciding whether to disclose information to their healthcare providers. They weigh the kind of information they will share, and how sharing some information might lead to embarrassment and judgment.

CONCLUSION

Mitigating the potentially counteractive effects of self-presentation on disclosure and working to foster contexts that encourage honest disclosure of health information may help to reduce health care inequalities.