Provider Implicit Racial Bias in Pediatric Sickle Cell Disease

BACKGROUND/OBJECTIVES

This study is to (1) assess implicit racial bias among pediatric providers and (2) use virtual patient (VP) vignettes to determine the impact of implicit racial bias on clinical decision-making in pediatric sickle cell disease (SCD) pain care.

DESIGN/METHODS

This cross-sectional study was conducted at a mid-sized, freestanding children's hospital in the northeast. Participants (N = 52) were pediatric SCD providers (87% cisgender female, 90% White, M age = 38.78). Providers completed a demographic questionnaire, the race Implicit Association Test (IAT) with adult and child faces, and a measure of SCD explicit bias (5-point Likert scale). Providers also made clinical decisions for four VP vignettes depicting Black and White youth in the emergency department (ED) with either SCD or cancer pain. Frequency tables were calculated.

RESULTS

On the race IAT, providers demonstrated a pro-White implicit bias for both adult (81%) and child (89%) faces. Responses to the explicit bias measure reflected low levels of agreement with negative stereotypes about SCD patients. No significant differences emerged in providers' pain treatment decisions for Black vs. White, or SCD vs. cancer VPs.

CONCLUSIONS

Findings indicate pediatric providers harbor implicit racial bias similar to the general population. Findings from VP vignettes did not demonstrate that pain treatment decision-making differed based on race or diagnosis. This may be due to standardized protocols and procedures in the pediatric emergency setting. Future research is needed to clarify the role of implicit bias in clinical decision-making and the potential efficacy of treatment protocols in preventing biases from interfering with pediatric SCD pain care.

Communication in Primary Healthcare: A State-of-the-Art Literature Review of Conversation-Analytic Research

We report the first state-of-the-art review of conversation-analytic (CA) research on communication in primary healthcare. We conducted a systematic search across multiple bibliographic databases and specialist sources and employed backward and forward citation tracking. We included 177 empirical studies spanning four decades of research and 16 different countries/health systems, with data in 17 languages. The majority of studies originated in United States and United Kingdom and focused on medical visits between physicians and adult patients. We generated three broad research themes in order to synthesize the study findings: managing agendas, managing participation, and managing authority. We characterize the state-of-the-art for each theme, illustrating the progression of the work and making comparisons across different languages and health systems, where possible. We consider practical applications of the findings, reflect on the state of current knowledge, and suggest some directions for future research. Data reported are in multiple languages.

Questions directed to children with diverse communicative competencies in paediatric healthcare consultations

OBJECTIVE

This paper examines question-response sequences, in which clinicians asked questions to child patients who appear to interact using means other than the verbal mode of communication.

METHODS

Conversation Analysis methods were used to study questions in 46 paediatric palliative care consultations. These questions were directed towards children who observably used vocalisations and embodied modes of communication (e.g., gaze, gesture and facial expressions) but did not appear to use the verbal mode.

RESULTS

Most questions asked children either about their willingness and preferences for a proposed next activity, or their current feelings, experiences or intentions. Questions involved children by foregrounding their preferences and feelings. These questions occasioned contexts where the child's vocal or embodied conduct could be treated as a relevant response.

CONCLUSION

This paper demonstrates how questions are used to involve children in consultations about their own healthcare, and how their views come to be understood by clinicians and family members, even when children interact using means other than the verbal mode of communication.

PRACTICE IMPLICATIONS

Questions can be asked of both children who do and do not verbally communicate. When asking questions, clinicians should be mindful of the modes of communication an individual child uses to consider how the child might meaningfully respond.

Questions to promote child-centered care in racially discordant interactions in pediatric oncology

OBJECTIVE

To examine questioning practices in racially discordant interactions and describe how these practices engendered child-centered care.

METHODS

We used applied conversation analysis to analyze a collection of 300 questions directed to children across 10 cases involving children of color and their families in disease reevaluation appointments in pediatric oncology.

RESULTS

Our analysis generated two patterns: 1) both the pediatric oncologists' and caregivers built upon one another's talk to enable the child's conversational turn, and 2) the oncologists' reformulated requests as questions to invite the child's permission and cooperation for completing exams and understanding symptoms.

CONCLUSION

Children, pediatric oncologists, and caregivers coordinated their actions to enable children to participate as recipients of and respondents to questions. The analysis of real-time interactions illuminates practices for centering children in clinical encounters and the benefits of doing so.

PRACTICAL IMPLICATIONS

This study's findings have implications for defining competencies and practices for fostering child-centered communication, creating training materials based on real-time encounters, and identifying strategies for humanizing pediatric patient experiences.

Cultural health capital and patient partner recruitment into healthcare improvement work

A rising emphasis on patient involvement in clinical research and healthcare improvement has led to the steady incorporation of patients and caregivers into this work. However, interactional factors shaping recruitment processes are not well understood. In this paper, we present a qualitative analysis of interviews with twenty-six patients, family members, engagement staff and healthcare providers who are engaged in healthcare improvement work in the United States. We focus on how stakeholders account for recruitment decisions to participate in healthcare improvement work. We find that expressions of and judgments about patients' and caregivers' cultural health capital shape providers' decisions to extend invitations to participate in healthcare improvement work. These findings extend current conceptualizations of cultural health capital beyond the clinical encounter to reveal factors shaping patient recruitment into healthcare improvement work. In theorizing how cultural health capital shapes action in this new setting, we found that healthcare providers, engagement staff, and patients/caregivers attended to different aspects of cultural health capital when accounting for why they extended or received a recruitment pitch. We further found that participating in healthcare improvement work led to a boost in cultural health capital for patients and caregivers, which they could use to develop transmissible forms of cultural health capital for less centrally involved patients and caregivers. Finally, we describe how participants in healthcare improvement collaboratives account for a lack of diversity among partners. These findings help us hypothesize the consequences of recruitment processes that rely on displays and judgments of cultural health capital and identify possibilities for change. Using the case of healthcare improvement work in Collaborative Learning Health Systems, our findings advance past work on cultural health capital in medical sociology by theorizing the role of cultural health capital in recruitment processes.

Making Conversation Analysis Accessible: A Conceptual Guide for Health Services Researchers

The quality of healthcare communication can impact both experiences and outcomes. We highlight aspects of communication that can be systematically examined using Conversation Analysis (CA) and provide guidance about how researchers can incorporate CA into healthcare studies. CA is a qualitative method for studying naturally occurring communication by analyzing recurrent, systematic practices of verbal and nonverbal behavior. CA involves examining audio- or video-recorded conversations and their transcriptions to identify practices speakers use to communicate and interpret behavior. We explain what distinguishes CA from other methods that study communication and highlight three accessible CA approaches that researchers can use in their research design, analysis, or implementation of communication interventions. Specifically, these approaches focus on how talk is produced (specific words, framing, and syntax), by whom, and when it occurs in the conversation. These approaches can be leveraged to generate hypotheses and to identify patterns of behavior that inform empirically driven communication interventions.

Antiracism, Black Lives Matter, and Critical Race Theory: The ABCs of Promoting Racial Equity in Pediatric Practice

Police shootings of unarmed Black men, women, and children at the intersection of disparities in the setting of the coronavirus disease 2019 pandemic have resulted in a long overdue national awakening regarding race and racism in society. This article defines some of the key terms, providing a foundation to help promote equity in pediatric practice. Although no single article can result in full competency regarding such complex issues, it is meant to provide a foundation for pediatricians on a journey to deepen their knowledge and understanding toward a path to action. [Pediatr Ann. 2022;51(3):e95-e106.].

What COVID-19 Teaches Us About Implicit Bias in Pediatric Health Care

OBJECTIVES

To highlight the role of implicit bias in contributing to existing health disparities among pediatric populations during the coronavirus disease 2019 (COVID-19) pandemic and recommend strategies to reduce its impact.

METHODS

A topical review of the recent literature on implicit bias describing its potential impact in key areas of pediatric health care within the context of COVID-19 was conducted.

RESULTS

Pediatric provider implicit bias has been found to be similar to the general population and can negatively influence clinical decision-making and outcomes for marginalized youth and families, particularly under stressful conditions such as the COVID-19 pandemic. Implicit bias can be mitigated through strategies proposed at the individual, institutional/organizational, educational, and scientific/research levels.

CONCLUSIONS

The additional strain on provider resources, staff, and supplies created by COVID-19 may exacerbate providers' susceptibility to implicit bias and contribute to health disparities. Pediatric psychologists are encouraged to recognize implicit biases in themselves and colleagues and promote identified strategies to reduce the impact of implicit bias on perpetuating health disparities in marginalized youth and families.

Addressing implicit bias in pediatric hematology-oncology

Although awareness of implicit bias and its influence on providers and patients is increasing, the effects of implicit bias on the field of pediatric hematology-oncology are less clear. This Special Report reviews the literature on implicit bias in pediatrics and medical oncology and further provides case examples and suggestions on what can be done to address implicit bias. There is a need for further research on how implicit bias impacts the complex care of pediatric hematology-oncology patients.

Racial Bias and Its Impact on Children and Adolescents

Racial bias is pervasive throughout society and can impact children and adolescents in the health care, education, and criminal justice systems. This article provides a state-of-the-science review of implicit bias in health care. It also reviews the evidence of how bias impacts children in other aspects of society, explores bias as it relates to the broader context of structural racism in America, and summarizes the impact of bias and discrimination on youth academic, behavioral, and health outcomes. Evidence-based strategies are provided to help pediatricians identify and confront their own personal biases.

Ageism in Health Care: A Systematic Review of Operational Definitions and Inductive Conceptualizations

PURPOSE

International and national bodies have identified tackling ageism in health care as an urgent goal. However, health professionals, researchers, and policy makers recognize that it is not easy to identity and fight ageism in practice, as the identification of multiple manifestations of ageism is dependent on the way it is defined and operationalized. This article reports on a systematic review of the operational definitions and inductive conceptualizations of ageism in the context of health care.

DESIGN AND METHODS

We reviewed scientific articles published from January 1995 to June 2015 and indexed in the electronic databases Web of Science, PubMed, and Cochrane. Electronic searches were complemented with visual scanning of reference lists and hand searching of leading journals in the field of ageing and social gerontology.

RESULTS

The review reveals that the predominant forms of operationalization and inductive conceptualization of ageism in the context of health care have neglected some components of ageism, namely the self-directed and implicit components. Furthermore, the instruments used to measure ageism in health care have as targets older people in general, not older patients in particular.

IMPLICATIONS

The results have important implications for the advancement of research on this topic, as well as for the development of interventions to fight ageism in practice. There is a need to take into account underexplored forms of operationalization and inductive conceptualizations of ageism, such as self-directed ageism and implicit ageism. In addition, ageism in health care should be measured by using context-specific instruments.

Assessment and Treatment Recommendations for Pediatric Pain: The Influence of Patient Race, Patient Gender, and Provider Pain-Related Attitudes

Previous studies have documented that racial minorities and women receive poorer pain care than their demographic counterparts. Providers contribute to these disparities when their pain-related decision-making systematically varies across patient groups. Less is known about racial and gender disparities in children with pain or the extent to which providers contribute to these disparities. In a sample of 129 medical students (henceforth referred to as "providers"), Virtual Human methodology and a pain-related version of the Implicit Association Test (IAT) were used to examine the effects of patient race/gender on providers' pain assessment/treatment decisions for pediatric chronic abdominal pain, as well as the moderating role of provider implicit pain-related race/gender attitudes. Findings indicated that providers rated Black patients as more distressed (mean difference [MD] = 2.33, P < .01, standard error [SE] = .71, 95% confidence interval [CI] = .92, 3.73) and as experiencing more pain-related interference (MD = 3.14, P < .01, SE = .76, 95% CI = 1.63, 4.64) compared to White patients. Providers were more likely to recommend opioids for Black patients than White patients (MD = 2.41, P < .01, SE = .58, 95% CI = 1.05, 3.76). Female patients were perceived to be more distressed by their pain (MD = 2.14, P < .01, SE = .79, 95% CI = .58, 3.70) than male patients, however there were no gender differences in treatment recommendations. IAT results indicated that providers held implicit attitudes that Black Americans (M = .19, standard deviation [SD] = .29) and males (M = .38, SD = .29) were more pain-tolerant than their demographic counterparts; however, these implicit attitudes did not significantly moderate their pain assessment/treatment decisions. Future studies are needed to elucidate specific paths through which the pain experience and care of children differ across racial and gender groups. PERSPECTIVE: Providers' pain assessment (ie, pain distress/pain interference) and treatment (ie, opioids) of pediatric pain differs across patient race and to a lesser extent, patient gender. This study represents a critical step in research on pain-related disparities in pediatric pain.

The power of suggestion: examining the impact of presence or absence of shared first language in the antenatal clinic

Healthcare encounters involving participants from diverse linguistic backgrounds are becoming more common due to the globalisation of health care and increasing migration levels. Research suggests that this diversity has a significant impact on health outcomes; however less is known about how it is managed in the actual consultation process. This article presents an analysis of antenatal screening consultations video recorded in Hong Kong, using conversation analysis. We consider how the use of a second or subsequent language impacts on these consultations, and on discussions and decisions about further action. The presence or absence of shared first language did not appear to affect the extent to which particular courses of action were promoted or recommended. Recommendations were a common occurrence across consultations with and without shared first language. However, we argue that the routine use of recommendations can be consequential, as second language speakers may have more limited resources to interrogate or contest these. This finding has implications for the ability for professionals to maximise patient involvement in decision-making.

A Framework for Integrating Implicit Bias Recognition Into Health Professions Education

Existing literature on implicit bias is fragmented and comes from a variety of fields like cognitive psychology, business ethics, and higher education, but implicit-bias-informed educational approaches have been underexplored in health professions education and are difficult to evaluate using existing tools. Despite increasing attention to implicit bias recognition and management in health professions education, many programs struggle to meaningfully integrate these topics into curricula. The authors propose a six-point actionable framework for integrating implicit bias recognition and management into health professions education that draws on the work of previous researchers and includes practical tools to guide curriculum developers. The six key features of this framework are creating a safe and nonthreatening learning context, increasing knowledge about the science of implicit bias, emphasizing how implicit bias influences behaviors and patient outcomes, increasing self-awareness of existing implicit biases, improving conscious efforts to overcome implicit bias, and enhancing awareness of how implicit bias influences others. Important considerations for designing implicit-bias-informed curricula-such as individual and contextual variables, as well as formal and informal cultural influences-are discussed. The authors also outline assessment and evaluation approaches that consider outcomes at individual, organizational, community, and societal levels. The proposed framework may facilitate future research and exploration regarding the use of implicit bias in health professions education.

Unequal interactions: Examining the role of patient-centered care in reducing inequitable diffusion of a medical innovation, the human papillomavirus (HPV) vaccine

RATIONALE

Studies of inequities in diffusion of medical innovations rarely consider the role of patient-centered care.

OBJECTIVE

We used uptake of the human papillomavirus (HPV) vaccine shortly after its licensing to explore the role of patient-centered care.

METHODS

Using a longitudinal multi-site survey of US parents and adolescents, we assessed whether patient-centered care ratings might shape racial/ethnic and socioeconomic gaps at two decision points in the HPV vaccination process: (1) Whether a medical provider recommends the vaccine and (2) whether a parent decides to vaccinate.

RESULTS

We did not find evidence that the association of patient-centeredness with vaccination varies by parent education. In contrast, parent ratings of providers' patient-centeredness were significantly associated with racial/ethnic disparities in parents' reports of receiving a HPV vaccine recommendation from a provider: Among parents who rate patient-centered care as low, white parents' odds of receiving such a recommendation are 2.6 times higher than black parents' odds, but the racial/ethnic gap nearly disappears when parents report high patient-centeredness. Moderated mediation analyses suggest that patient-centeredness is a major contributor underlying vaccination uptake disparities: Among parents who report low patient-centeredness, white parents' odds of vaccinating their child are 8.1 times higher than black parents' odds, while both groups are equally likely to vaccinate when patient-centeredness is high.

CONCLUSION

The results indicate that patient-centered care, which has been a relatively understudied factor in the unequal diffusion of medical innovations, deserves more attention. Efforts to raise HPV vaccination rates should explore why certain patient groups may be less likely to receive recommendations and should support providers to consistently inform all patient groups about vaccination.

Comparison of Physician Implicit Racial Bias Toward Adults Versus Children

BACKGROUND AND OBJECTIVES

The general population and most physicians have implicit racial bias against black adults. Pediatricians also have implicit bias against black adults, albeit less than other specialties. There is no published research on the implicit racial attitudes of pediatricians or other physicians toward children. Our objectives were to compare implicit racial bias toward adults versus children among resident physicians working in a pediatric emergency department, and to assess whether bias varied by specialty (pediatrics, emergency medicine, or other), gender, race, age, and year of training.

METHODS

We measured implicit racial bias of residents before a pediatric emergency department shift using the Adult and Child Race Implicit Association Tests (IATs). Generalized linear models compared Adult and Child IAT scores and determined the association of participant demographics with Adult and Child IAT scores.

RESULTS

Among 91 residents, we found moderate pro-white/anti-black bias on both the Adult (mean = 0.49, standard deviation = 0.34) and Child Race IAT (mean = 0.55, standard deviation = 0.37). There was no significant difference between Adult and Child Race IAT scores (difference = 0.06, P = .15). Implicit bias was not associated with resident demographic characteristics, including specialty.

CONCLUSIONS

This is the first study demonstrating that resident physicians have implicit racial bias against black children, similar to levels of bias against black adults. Bias in our study did not vary by resident demographic characteristics, including specialty, suggesting that pediatric residents are as susceptible as other physicians to implicit bias. Future studies are needed to explore how physicians' implicit attitudes toward parents and children may impact inequities in pediatric health care.

‘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.

Effect of question design on dietary information solicited during veterinarian-client interactions in companion animal practice in Ontario, Canada

OBJECTIVE

To establish the types of initial questions used by veterinarians in companion animal practice to solicit nutritional history information from owners of dogs and cats, the dietary information elicited, and the relationship between initial question-answer sequences and later nutrition-related questions.

DESIGN

Cross-sectional qualitative conversation analytic study.

SAMPLE

98 appointments featuring 15 veterinarians drawn from an observational study of 284 videotaped veterinarian-client-patient visits involving 17 veterinarians in companion animal practices in eastern Ontario, Canada.

PROCEDURES

Veterinarian and client talk related to patient nutrition was identified and transcribed; conversation analysis was then used to examine the orderly design and details of talk within and across turns. Nutrition-related discussions occurred in 172 visits, 98 of which contained veterinarian-initiated question-answer sequences about patient nutritional history (99 sequences in total, with 2 sequences in 1 visit).

RESULTS

The predominant question format used by veterinarians was a what-prefaced question asking about the current content of the patient's diet (75/99). Overall, 63 appointments involved a single what-prefaced question in the first turn of nutrition talk by the veterinarian (64 sequences in total). Dietary information in client responses was typically restricted to the brand name, the subtype (eg, kitten), or the brand name and subtype of a single food item. When additional diet questions were subsequently posed, they typically sought only clarification about the food item previously mentioned by the client.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that question design can influence the accuracy and completeness of a nutritional history. These findings can potentially provide important evidence-based guidance for communication training in nutritional assessment techniques.

"You Can Turn off the Light If You'd Like": Pediatric Health Care Visits for Children with Autism Spectrum Disorder as an Interactional Achievement

Substantial scholarship has been generated in medical anthropology and other social science fields on typically developing child-parent-doctor interactions during health care visits. This article contributes an ethnographic, longitudinal, discourse analytic account of a child with autism spectrum disorder (ASD)-parent-doctor interactions that occur during pediatric and neurology visits. The analysis shows that when a child with ASD walks into the doctor's office, the tacit expectations about the visit may have to be renegotiated to facilitate the child's, the parent's, and the doctor's participation in the interaction. A successful visit then becomes a hard-won achievement that requires the interactional and relational work of all three participants. We demonstrate that communicative and sensory limitations imposed by ASD present unique challenges to all the participants and consider how health care disparities may invade the pediatric encounter, making visible the structural and interactional processes that engender them.

Motivational interviewing interactions and the primary health care challenges presented by smokers with low motivation to stop smoking: a conversation analysis

Background

Research indicates that one third of smokers have low motivation to stop smoking. The purpose of the study was to use Conversational Analysis to enhance understanding of the process in Motivational Interviewing sessions carried out by primary care doctors and nurses to motivate their patients to quit smoking. The present study is a substudy of the Systematic Intervention on Smoking Habits in Primary Health Care Project (Spanish acronym: ISTAPS).

Methods

Motivational interviewing sessions with a subset of nine participants (two interview sessions were conducted with two of the nine) in the ISTAPS study who were current smokers and scored fewer than 5 points on the Richmond test that measures motivation to quit smoking were videotaped and transcribed. A total of 11 interviews conducted by five primary health care professionals in Barcelona, Spain, were analysed. Qualitative Content Analysis was used to develop an analytical guide for coding transcriptions. Conversation Analysis allowed detailed study of the exchange of words during the interaction.

Results

Motivational Interviewing sessions had three phases: assessment, reflection on readiness to change, and summary. The interaction was constructed during an office visit, where interactional dilemmas arise and can be resolved in various ways. Some actions by professionals (use of reiterations, declarations, open-ended questions) helped to construct a framework of shared relationship; others inhibited this relationship (focusing on risks of smoking, clinging to the protocol, and prematurely emphasizing change). Some professionals tended to resolve interactional dilemmas (e.g., resistance) through a confrontational or directive style. Interactions that did not follow Motivational Interviewing principles predominated in seven of the interviews analysed.

Conclusions

Conversational analysis showed that the complexity of the intervention increases when a health professional encounters individuals with low motivation for change, and interactional dilemmas may occur that make it difficult to follow Motivational Interview principles. Incorporating different forms of expression during the Motivational Interviewing could help to build patient-centred health care relationships and, for patients with low motivation to stop smoking, offer an opportunity to reflect on tobacco use during the office visit. The study findings could be included in professional training to improve the quality of motivational interviewing.

Conveying information in the interpreter-mediated medical visit: the case of epistemic brokering

OBJECTIVE

This study introduces the concept of epistemic brokering in interpreter-mediated medical visits and illustrates how it can be used to effectively convey information between providers and patients/parents.

METHODS

Conversation analysis is used to analyze 24 pediatric genetics consultations (=17.75 h) involving 16 Spanish-speaking families, their various English-speaking healthcare providers, and four on-staff bilingual interpreters.

RESULTS

Interpreters-as-epistemic-brokers can aid in the transfer of information between clinicians and patients/parents (i) by (re)designing content to be appropriately fitted to a specific recipient's understanding, and (ii) by monitoring the ongoing medical visit for moments in which one or more interactants may be in a relatively unknowledgeable position and taking steps to secure common ground.

CONCLUSION

It is posited that epistemically brokering interaction can serve to promote the development of positive relationships with potentially hard-to-reach patients/parents. Although seemingly minor, these moments in interaction contribute to these individuals' overall experience with and understanding of the institution of medicine. Future research is needed to identify the particular strategies associated with effective epistemic brokering.

PRACTICE IMPLICATIONS

Interpreters and clinicians should be aware of the role that discursive practices play in conveying information in the medical visit, and reconceptualize interpreters as collaborators in this process.

An evaluation of physicians' engagement of children with asthma in treatment-related discussions

Our objectives were to examine whether providers engage children with asthma in treatment-related discussions at the level children prefer (engagement concordance) and to determine whether engagement concordance is related to child, caregiver, and provider characteristics. Children with asthma (n = 296) aged 8-16 years were recruited at five pediatric practices in North Carolina. Using audiotaped medical visit transcripts, we documented the number of treatment-related questions the providers asked the children. Children reported their preferred level of provider engagement. A logistic generalized estimating equation was used to determine which variables predicted engagement concordance. Most children (96.6%) wanted to be involved in treatment-related discussions. One-third of the providers did not ask children any treatment-related questions. Only 36.1% of provider-child dyads were concordant. Most discordant dyads were under-engaged (83.1%). Better engagement concordance was observed among older children (odds ratio (OR) = 1.19, 95% confidence interval (CI) (1.07, 1.33)), male children (OR = 1.67, 95% CI (1.03, 2.70)), and among providers with fewer years in practice (OR = .97, 95% CI (.94, .99)). Providers engaged in treatment-related discussions with younger children and females less frequently than these children preferred. Providers should ask children how much they want to be involved in treatment-related discussions and then attempt to engage children at the level they prefer.

Relationship between Expectation Management and Client Retention in Online Cognitive Behavioural Therapy

BACKGROUND

Engaging clients from the outset of psychotherapy is important for therapeutic success. However, there is little research evaluating therapists' initial attempts to engage clients in the therapeutic process. This article reports retrospective analysis of data from a trial of online cognitive behavioural therapy (CBT) for depression. Qualitative and quantitative methods were used to evaluate how therapists manage clients' expectations at the outset of therapy and its relationship with client retention in the therapeutic intervention.

AIMS

To develop a system to codify expectation management in initial sessions of online CBT and evaluate its relationship with retention.

METHOD

Initial qualitative research using conversation analysis identified three communication practices used by therapists at the start of first sessions: no expectation management, some expectation management, and comprehensive expectation management. These findings were developed into a coding scheme that enabled substantial inter-rater agreement (weighted Kappa = 0.78; 95% CI: 0.52 to 0.94) and was applied to all trial data.

RESULTS

Adjusting for a range of client variables, primary analysis of data from 147 clients found comprehensive expectation management was associated with clients remaining in therapy for 1.4 sessions longer than those who received no expectation management (95% CI: -0.2 to 3.0). This finding was supported by a sensitivity analysis including an additional 21 clients (1.6 sessions, 95% CI: 0.2 to 3.1).

CONCLUSIONS

Using a combination of qualitative and quantitative methods, this study suggests a relationship between expectation management and client retention in online CBT for depression, which has implications for professional practice. A larger prospective study would enable a more precise estimate of retention.

How communication affects prescription decisions in consultations for acute illness in children: a systematic review and meta-ethnography

Background

Communication within primary care consultations for children with acute illness can be problematic for parents and clinicians, with potential misunderstandings contributing to over–prescription of antibiotics. This review aimed to synthesise the evidence in relation to communication and decision making in consultations for children with common acute illness.

Methods

A systematic search of MEDLINE, EMBASE, CINAHL, PsycINFO, SSCI, SIGLE, Dissertation Express and NHS economic evaluation databases was conducted. Studies of primary care settings in high income countries which made direct observations of consultations and reported qualitative data were included. Included studies were appraised using the process recommended by the Cochrane Qualitative Methods Group. Credibility was assessed as high for most studies but transferability was usually assessed low or unclear. Data were synthesised using a meta–ethnographic approach.

Results

Thirty–five papers and 2 theses reporting on 13 studies were included, 7 of these focussed on children with respiratory tract infections (RTI) and the remaining 6 included children with any presenting illness. Parent communication focussed on their concerns and information needs, whereas clinician communication focussed on diagnosis and treatment decisions. During information exchanges, parents often sought to justify the need for the consultation, while clinicians frequently used problem minimising language, resulting in parents and clinicians sometimes talking at cross–purposes. In the context of RTIs, a range of parent communication behaviours were interpreted by clinicians as indicating an expectation for antibiotics; however, most were ambiguous and could also be interpreted as raising concerns or requests for further information. The perceived expectation for antibiotics often changed clinician decision making into clinician–parent negotiation.

Conclusions

Misunderstandings occurred due to parents and clinicians talking at cross purposes about the ‘seriousness’ of the illness and because parents’ expressions of concern or requests for additional information were sometimes perceived as a challenge to the clinicians’ diagnosis or treatment decision. This modifiable problem may be an important contribution to the unnecessary and unwanted prescribing of antibiotics. Primary care clinicians should be offered training to understand parent communication primarily as expressions of concern or attempts at understanding and always to check rather than infer parental expectations.

Transition readiness in adolescents and emerging adults with diabetes: the role of patient-provider communication

Transition from pediatric to adult care represents a high risk period for adolescents and emerging adults with diabetes. Fundamental differences between pediatric and adult care delivery models may contribute to increased risk for poor health outcomes. This review provides a brief overview of models of care in pediatric and adult settings and focuses on patient-provider communication content and quality as potential points of intervention to improve transition-related outcomes. This review also highlights disparities in transition and communication for adolescents and emerging adults from racial/ethnic minority groups and discusses recent changes in health care legislation that have significant implications for the transition process. Intervention opportunities include programs to enhance developmentally-appropriate patient-provider interactions and increased attention to promoting transition readiness skills. Improving patient-provider communication may hasten the development of vital self-advocacy skills needed in adult health care systems and, thus, help establish a lasting pattern of positive diabetes self-care.

Unpacking “Self”

Goffman’s work on footing has paved the way to specifying the analytic concepts of speaker and hearer in social interaction. This article empirically examines participants’ moment-by-moment negotiated understandings of speakerhood in the context of conversational repair—sequences of talk dedicated to resolving problems of hearing, speaking, or understanding. I demonstrate that participation in repair sequences reflects interactants’ orientations to socially distributed rights to knowledge, or epistemics. Even though speakers are ordinarily entitled to speak on their own behalf and, thus, to repair their own talk, the application of this right is a contingent, negotiated, and sometimes contested matter. Using the methodology of conversation analysis to examine a large corpus of video-recorded English, Russian, and bilingual multiparty interactions, I show how asymmetries in participants’ experiences and expertise are drawn upon in the process of repair resolution, suggesting a respecification of the notion of “self” as it pertains to repair.

Systematically reviewing and synthesizing evidence from conversation analytic and related discursive research to inform healthcare communication practice and policy: an illustrated guide

Background

Healthcare delivery is largely accomplished in and through conversations between people, and healthcare quality and effectiveness depend enormously upon the communication practices employed within these conversations. An important body of evidence about these practices has been generated by conversation analysis and related discourse analytic approaches, but there has been very little systematic reviewing of this evidence.

Methods

We developed an approach to reviewing evidence from conversation analytic and related discursive research through the following procedures:

• reviewing existing systematic review methods and our own prior experience of applying these

• clarifying distinctive features of conversation analytic and related discursive work which must be taken into account when reviewing

• holding discussions within a review advisory team that included members with expertise in healthcare research, conversation analytic research, and systematic reviewing

• attempting and then refining procedures through conducting an actual review which examined evidence about how people talk about difficult future issues including illness progression and dying

Results

We produced a step-by-step guide which we describe here in terms of eight stages, and which we illustrate from our ‘Review of Future Talk’. The guide incorporates both established procedures for systematic reviewing, and new techniques designed for working with conversation analytic evidence.

Conclusions

The guide is designed to inform systematic reviews of conversation analytic and related discursive evidence on specific domains and topics. Whilst we designed it for reviews that aim at informing healthcare practice and policy, it is flexible and could be used for reviews with other aims, for instance those aiming to underpin research programmes and projects. We advocate systematically reviewing conversation analytic and related discursive findings using this approach in order to translate them into a form that is credible and useful to healthcare practitioners, educators and policy-makers.

Physician-child interaction: when children answer physicians' questions in routine medical encounters

OBJECTIVE

The objective of the study is to examine predictors of children answering questions during primary care pediatric visits.

METHODS

Relying on a sample of 322 video-taped community practice encounters, this study identifies predictors of when children answer physicians' questions. Multi-level multivariate regressions were used to model the relationships among communication and socio-demographic variables and whether or not children answered questions pediatricians asked them.

RESULTS

Whereas race and education predict whether physicians select children to answer questions, these factors are not associated with whether children answer physicians' questions. Instead, a child's performance is associated with communication practices specific to physician-child interaction such as the grammatical type of question and doctor gaze.

CONCLUSION

Children are less responsive to physicians' questions than their parents but their failure to answer is predictable and thus can be improved. By increasing their participation in the visit, physicians may (a) secure more information about children's health and (b) socialize children to be more pro-active patients.

PRACTICE IMPLICATIONS

Physicians can improve the likelihood that children will answer their questions by (a) asking them social questions early in the visit, (b) phrasing their questions as yes-no questions, and (c) and directing their gaze at the children during each question.

Helping medical learners recognise and manage unconscious bias toward certain patient groups

CONTEXT

For the last 30 years, developments in cognitive sciences have demonstrated that human behaviour, beliefs and attitudes are shaped by automatic and unconscious cognitive processes. Only recently has much attention been paid to how unconscious biases based on certain patient characteristics may: (i) result in behaviour that is preferential toward or against specific patients; (ii) influence treatment decisions, and (iii) adversely influence the patient-doctor relationship. Partly in response to accreditation requirements, medical educators are now exploring how they might help students and residents to develop awareness of their own potential biases and strategies to mitigate them.

METHODS

In this paper, we briefly review key cognition concepts and describe the limited published literature about educational strategies for addressing unconscious bias.

DISCUSSION

We propose a developmental model to illustrate how individuals might move from absolute denial of unconscious bias to the integration of strategies to mitigate its influence on their interactions with patients and offer recommendations to educators and education researchers.

Information-seeking coping behaviors during painful procedures in African-American children with sickle cell disease

This study examined the frequency of information-seeking coping behaviors in 37 African-American children (ages 5-17 years) with sickle cell disease during venipuncture. The relationships between coping behaviors and child- and parent-reported pain and observational distress were also assessed. The majority of children attended to the procedure, but did not seek information via questions. This pattern of coping was only partially effective at reducing distress and had no relation to pain. This pattern of coping is discussed within the context of cultural factors that may be important in understanding responses to procedural pain in pediatric sickle cell disease.

Medical Discourse

Discourse plays an important role in medicine, and medical discourse in the broadest sense (discourse in and about healing, curing, or therapy; expressions of suffering; and relevant language ideologies) has profound anthropological significance. As modes of social action, writing and speaking help constitute medical institutions, curative practices, and relations of authority in and beyond particular healing encounters. This review describes cultural variation in medical discourse and variation across genres and registers. It then surveys two approaches to analyzing medical discourse: conversation analysis (CA) and discourse studies echoing Foucault's work, attempting to spur dialogue between them. Such dialogue could be fruitful because, despite hesitancy to invoke macrosocial variables, conversation analysts as well as Foucaultian discourse analysts have reflected on medical authority. Finally, the article reviews recent attempts to contextualize closely analyzed interactions—written exchanges as well as face-to-face clinical encounters—vis-à-vis the global circulation of linguistic forms and ideologies.

Beyond 'doctor and patient': developments in the study of healthcare interactions

Three decades of conversation analytic investigations of medical interaction have produced a rich collection of findings of sociological interest, from a diverse array of encounters. This paper briefly outlines the development of this field to provide a context for the special issue. The paper discusses how studies of doctor-patient interaction have revealed the ways in which participants organise the medical visit to accomplish tasks such as diagnosing and recommending treatment for illness, and how doctors and patients address various interactional issues and dilemmas that arise as they undertake these tasks. It then highlights a growing number of CA studies that explore medical settings and activities beyond the doctor-patient encounter. In doing so, it charts the distinctive interactional practices that emerge, for example, where participants are engaging in hands-on treatment, medical practitioners are interacting with one another, or various technologies are employed during the encounter. Finally, papers in this special issue are introduced and shown to build upon this latter tradition. The papers address distinctive practical problems and institutional dilemmas that arise in healthcare encounters and medical settings beyond dyadic doctor-patient interaction, with a focus on the participants' orientations to policy, their distinctive modes of participation, and the use of technology.

Perceptions of participation: child patients with a disability in the doctor-parent-child partnership

OBJECTIVE

To explore how the doctor-parent-child partnership is experienced and if the child patient is considered a contributor.

METHODS

Qualitative methodology using semi-structured interviews with 33 participants (9 paediatricians, 14 parents, and 10 children aged 8-12 with cerebral palsy) from a paediatric teaching hospital in Victoria, Australia.

RESULTS

Children were reported to participate in the doctor-parent-child partnership. The child was not perceived to be an 'equal' or 'regular' partner as there were reports of variability in the involvement between children, as well as variability in the progressive involvement of each child. Three categories emerged in relation to the child's position in the partnership: creating a space for the child's involvement; acknowledging the variability of child preferences to be involved; and negotiating the child's age and development.

CONCLUSION

The doctor-parent-child partnership was perceived not necessarily to be dyadic, shared exclusively by the parent and paediatrician. Children were reported to contribute to the partnership, although there were limitations to the child's involvement.

PRACTICE IMPLICATIONS

Previous understandings of partnership are not sufficient to explain the complexities involved in a doctor-parent-child partnership, and a social-model approach to care is highlighted as an important factor for enabling the development of a triadic partnership.