Fitting proposals to their sequential environment: a comparison of turn designs for proposing treatment in ongoing outpatient psychiatric consultations in Japan

Treatment decision making in psychiatry: Formulating patients’ perspectives in outpatient psychiatric consultations

Seeking and understanding patients’ values and preferences is one of the essential elements in shared decision making, which is associated with treatment adherence in psychiatry. However, negotiating treatment in psychiatric contexts can be challenging with patients whose ability to evaluate treatment recommendations rationally may be impaired. This article attempts to examine a conversational practice that psychiatrists use to deal with patients’ views and perspectives by formulating what the patients have said related to treatment. Taking the naturally occurring, face-to-face outpatient psychiatric consultations as the data, the present study uses conversation analysis (CA) as a method to demonstrate in a fine-grained detail what functions formulations of patients’ perspectives serve in psychiatric contexts. We found that by eliciting patients’ views and perspectives toward treatment, this type of formulation is not only used to achieve mutual understanding and establish the grounds for treatment decisions, but may also be used to challenge the legitimacy of patients’ position, steering treatment decision to the direction preferred by the psychiatrists. We argue that in the process of treatment decision making, psychiatrists do not simply impose their perspectives upon the patients, instead, they attempt to achieve consensus with patients by balancing their institutional authority and orientation to the patients’ perspectives. Data are in Chinese with English translation.

The Role of Health Care Communication in Treatment Outcomes

The physician-patient relationship has evolved significantly in the past century. Physician authority has been reduced while patients have been empowered. This review focuses on face-to-face clinical care and argues that current physician-patient relations range from partnerships between social actors who each play critical roles in negotiating care to a more adversarial duel in which both participants advocate for goals that are not necessarily shared. While the former is the hope of increased patient involvement, the latter is increasingly common. Through our discussion of existing studies, we document that while high levels of patient participation are beneficial to treatment outcomes, this engagement also has a dark side that threatens treatment outcomes. We discuss some communication resources patients use that affect treatment outcomes, exemplify how patient engagement affects physician communication, and discuss some strategies that current research finds effective for communicating about treatment with today's engaged patients.

Subsequent Actions Engendered by the Absence of an Immediate Response to the Proposal in Mandarin Mundane Talk

When there is no immediate response after a proposal and normally the silence is longer than 0.2 s, the proposer would take subsequent actions to pursue a preferred response or mobilize at least an articulated one from the recipient. These actions modulate the prior deontic stance embedded in the original proposal into four trends as follows: (1) maintaining the prior deontic stance with a self-repair or by seeking confirmation; (2) making the prior deontic stance more tentative by making a revised other-attentiveness proposal, providing an account, pursuing with a tag question, or requesting with an intimate address term; (3) making the prior deontic stance more decisive by making a further arrangement (for the original proposal), closing the local sequence, or providing a candidate unwillingness account (for the recipient's potential rejection); and (4) canceling the prior deontic stance by doing a counter-like action. Additionally, these trends inherently embody a decisive-to-tentative gradient. This study would penetrate into the phenomena occurring in Mandarin mundane talk with the methodology of Conversation Analysis to uncover the underflow of deontic stance.

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

Globally, 4.4% of the world's population suffer from depressive disorder, and 3.6% from anxiety disorder. Previous work found considerable negotiation between providers and patients about the nature of mental health problems and frequent patient resistance to treatment. However, how doctor-patient shared understanding of the problem is reflected in treatment recommendations and whether this is consequential for patient acceptance of treatment is poorly understood. This study explored shared understanding of the problem and patient acceptance of treatment using conversation analysis. In 52 U.K. video recorded primary care consultations (collected July 2014-April 2015), 33 treatment recommendations for medication or talking therapy were identified. Shared understanding was explored focusing on: whether the patient presented the mental health problem as their primary initial concern and how they characterised the concern; whether the mental health concern was raised by the patient; and how the doctor aligned with the patient's earlier characterisation of the problem in the treatment recommendation itself. These phenomena were coded for each treatment recommendation and the impact on treatment acceptance was explored. Patients accepted the recommendation immediately in 38% cases and actively resisted in 62% cases. However, two communication behaviors were associated with patient acceptance: recommending treatment for the patient's initial focal concern and doctors' turn design in the recommendation itself, i.e., using the patient's earlier words from the initial problem presentation to describe and characterise the problem. Given the global burden of mental health problems and frequent patient resistance to treatment, understanding how professionals can engage more closely with the patient's perspective is important. When doctors use the patient's precise words from the initial problem presentation in the treatment recommendation, this displays an understanding of the patient's perspective and personalisation of treatment based on the underlying biomedical or social causes, which then impacts on patient acceptance of treatment.

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.

Discussing Hearing Aid Rehabilitation at the Hearing Clinic: Patient Involvement in Deciding upon the Need for a Hearing Aid

The quality of interaction between hearing health professionals and patients is one prominent, yet under-studied explanation for the low adherence in acquiring and using a hearing aid. This study describes two different ways of introducing hearing aid to the patients at their first visits at the hearing clinic: an inquiry asking patients opinion followed by offer, and an expert evaluation of the necessity of a hearing aid; and shows two different trajectories ensuing from these introductions. The trajectories represent two extreme ends of a continuum of practices of starting a discussion about hearing aid rehabilitation, in terms of how these practices affect patient participation in decision-making. The analysis shows how granting different degrees of deontic and epistemic rights to professionals and patients has different consequences with regard to the activity of reaching shared understanding on the treatment. The data consist of 17 video-recorded encounters at the hearing clinic. The method used is conversation analysis.

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.

Treatment Recommendations in Oncology Visits: Implications for Patient Agency and Physician Authority

Although oncology is a major site for clinician‒patient treatment negotiation requiring a careful balance of potentially competing viewpoints, little is known about how clinicians promote their treatment recommendations to patients and what the manner of promotion tells us about the oncologist‒patient relationship. Utilizing an already-established schema of coding treatment recommendations, I draw on 61 treatment recommendations to examine treatment decision-making in oncology. This paper investigates how physicians balance asserting their authority while at the same time attending to patient agency and involvement in decision-making. Taking this one step further, this paper explores how physicians negotiate decision-making with patients given that they occupy a liminal state between obligations to policy imperatives and commitments to their professional knowledge and technical expertise. How do they do this, and what accounts for this? To answer these questions, this paper analyzes the ways in which physicians present treatment recommendations and the treatment contexts in which they are made.

How clients solicit medication changes in psychiatry

In psychiatry, practitioners are encouraged to adopt a patient-centred approach that emphasises shared decision-making. In this article, we investigate how clients with severe mental illnesses (e.g. schizophrenia) advocate for their treatment preferences in psychiatric consultations. The study uses Conversation Analysis to examine audio-recorded medication check appointments in a comprehensive treatment programme known as assertive community treatment (ACT). The analysis shows that clients solicit medication changes at activity boundaries and design them in one of the following ways: reporting a physical problem; reporting a medication problem; explicitly requesting a medication change; and demanding a change. These formats put pressure on the psychiatrist to respond by either offering a solution to the client's problem or by accepting or rejecting the client's request. Through a detailed analysis of clients' communicative behaviours, we show that, in soliciting a medication change, clients ordinarily respect boundaries of medical authority and present themselves as 'good' patients who are reliable witnesses of their own experiences. Overall, the paper advances our understanding of patient advocacy in psychiatry and mental health interactions more generally.

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.

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?

Treatment Recommendations as Actions

From the earliest studies of doctor-patient interaction (Byrne & Long, 1976), it has been recognized that treatment recommendations may be expressed in more or less authoritative ways, based on their design and delivery. There are clear differences between I'm going to start you on X and We can give you X to try and Would you like me to give you X? Yet little is known about this variation, its contexts, or its consequences. In this paper, we develop a basic taxonomy of treatment recommendations in primary care as a first step toward a more comprehensive investigation. We take as our point of departure the observation that treatment recommendations such as those above represent not only different formulations but also different social actions. We distinguish five main treatment recommendation actions: pronouncements, suggestions, proposals, offers, and assertions. We ask: what are the main dimensions on which these recommendations vary and to what end? And what sorts of factors shape a clinician's use of one action type over another with respect to recommending a medication in the primary care context?

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.