When patients and clinician (dis)agree about the nature of the problem: The role of displays of shared understanding in acceptance of treatment

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.

Engagement with emotional concerns in general practice: a thematic analysis of GP consultations

BACKGROUND

Emotional concerns (defined as any expression of low mood, anxiety, or psychosocial stress) are an important part of the biopsychosocial care model used in modern medical practice. Previous work has demonstrated variable engagement with emotional concerns and that improved communication has been associated with reductions in emotional distress.

AIM

To examine how emotional concerns are engaged with during routine GP consultations.

DESIGN & SETTING

Secondary study using the Harnessing Resources from the Internet (HaRI) database. The available dataset contains 231 recordings from 10 GPs across eight urban and suburban practices recorded in 2017 and 2018.

METHOD

The dataset was reviewed to identify any consultations containing emotional concerns (as defined as any expression of low mood, anxiety, or psychosocial stress) before being imported into NVivo (version 12) to facilitate thematic analysis and coding. Reflexive inductive thematic analysis resulted in two major themes.

RESULTS

The two main themes were as follows: engagement with emotional concerns as dynamic throughout consultations; and GPs engage with emotional concerns both diagnostically and therapeutically. In theme 1, this dynamism relates to competing areas of focus, immediate versus delayed engagement and reiteration of concerns throughout consultations. Emotional concerns can be engaged with in a similar way to physical concerns (theme 2) using a diagnostic and treatment-based approach; however, in addition to this, therapeutic listening and conversation is utilised.

CONCLUSION

Awareness of the dynamic nature of emotional concerns within consultations and encouraging engagement with concerns in a flexible and patient-oriented manner may help improve doctor-patient communication. In addition, investigating how GPs and patients build shared understanding around emotional concerns may identify methods to reduce patients' emotional distress.

Beyond the patient-doctor dyad: Examining "other" patient engagement in Traditional Chinese Medicine consultations

This paper explores the unique phenomenon of "other" patient participation in Traditional Chinese Medicine (TCM). Specifically, it focuses on cases where doctors enlist the help of bystanders to address patient resistance and advance their medical agendas. By analyzing video-recorded practitioner-patient interactions in TCM hospitals, this study uncovers the various roles that third parties can assume during these medical interactions. The research identifies three distinct forms of "other" patient participation: the "other" patient as an illness-free individual providing a contrasting case, the "other" patient as a lay witness to the patient's clinical manifestations, and the "other" patient as a recovered fellow patient demonstrating treatment effectiveness. The findings of this study contribute to existing research on patient resistance and triadic medical interactions, offering insights into the dynamics and implications of third-party involvement in medical consultations.

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.

Health Communication Research Informs Inflammatory Bowel Disease Practice and Research: A Narrative Review

Background

In the absence of targeted empirical evidence on effective clinical communication in inflammatory bowel disease (IBD), a broad overview of existing evidence on effective communication in healthcare and available recommendations for communication in telehealth is provided and mapped onto IBD research and practice.

Methods

A narrative literature review was conducted using Pubmed and Scopus databases and snowballing literature search.

Results

Evidence-based relationship building strategies include communicating emotions, acknowledging and addressing patients' hesitancy, and ensuring continued support. A particular recommendation regarding telehealth interaction is to avoid long stretches of talk. Effective informational strategies include facilitating and supporting information exchange and considering patients' preferences in decision-making. In teleconsultations, clinicians should ask direct questions about patients' emotional state, clarify their understanding of patients' concerns and check patients' understanding, address at least one patient-reported outcome when discussing the recommended treatment, and shorten the consultation where possible. Strategies for maximizing effective clinical communication in the spoken communicative mode include using infographics and simple language, and assessing adherence at the beginning of the consultation. For teleconsultations, clinicians are advised to allow patients to explain the reason for their call at the beginning of the teleconsultation, probe additional concerns early and before ending the teleconsultation, and be mindful of technical issues such as voice delays.

Conclusions

Use of question prompt lists, decision aids, micro-lessons, and communication training interventions for clinicians could be beneficial in IBD care. Further research into the implementation of such interventions as well as clinical communication concerns specific to IBD is warranted.

Erasing inequality: Examining discrepancies between electronic health records and patient narratives to uncover perceived stigma and dismissal in clinical encounters

Current policy efforts to reduce health disparities focus on integrating patients' social determinants of health (SDHs) into their electronic health records (EHRs), with the goal of addressing both clinical and social risks through the health system. Yet clinicians' documentation of and engagement with patients' social characteristics may, in certain circumstances, actually contribute to health disparities. This paper compares accounts of clinical encounters from in-depth interviews with forty-six non-college-educated women against their EHR's codes and free-text notes, which document the clinician's perspective of the encounter. We identify how documentation of clinical encounters may exacerbate the very health disparities that health systems seek to intervene upon by 1) translating social suffering stemming from structural inequality into stigmatized risk factors, and 2) suppressing conflicts over diagnosis and treatment, sometimes by framing observations of women's social identities as evidence of their unreliability as patients. We demonstrate how perceived negative interactions lead some women to resist the health system, either by self-treating in ways that could adversely affect their health or by attempting to challenge the authority of clinicians, which is not documented as resistance in their medical charts.

Negative stance towards treatment in psychosocial assessments: The role of personalised recommendations in promoting acceptance

People presenting to the emergency department with self-harm or thoughts of suicide undergo a psychosocial assessment involving recommendations for e.g. contact with other practitioners, charity helplines or coping strategies. In these assessments, patients frequently adopt a negative stance towards potential recommendations. Analysing 35 video-recorded liaison psychiatry psychosocial assessments from an emergency department in England (2018-2019), we ask how these practitioners transform this negative stance into acceptance. We show that practitioners use three steps to anticipate and address negative stance (1) asking questions about the patient's experience/understanding that help the patient to articulate a negative stance (e.g., "what do you think about that"); (2) accepting or validating the reasons underlying the negative stance (e.g., "that's a very real fear and thought to have"); and (3) showing the patient that their reasons were incorporated in the recommendation (e.g., "it's telephone support if you're a bit more uncomfortable with face to face"). These steps personalise the recommendation based on the patient's specific experiences and understanding. When practitioners followed all three of these steps, the patient moved from a negative stance to acceptance in 84% of cases. When practitioners made a recommendation but did not follow all three steps, the patient moved from a negative stance to acceptance in only 14% of cases. It is not the case that each communication practice works on its own to promote patient acceptance, rather Steps 1 and 2 build on each other sequentially to develop and demonstrate shared understanding of the patient's negative stance. In this way, acceptance and validation play an indispensable role in addressing a patient's concerns about treatment.