1
|
Lian OS, Nettleton S, Grange H, Dowrick C. 'My cousin said to me . . .' Patients' use of third-party references to facilitate shared decision-making during naturally occurring primary care consultations. Health (London) 2024; 28:775-794. [PMID: 37519043 PMCID: PMC11323419 DOI: 10.1177/13634593231188489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
In this paper, we explore the ways in which patients invoke third parties to gain decision-making influence in clinical consultations. The patients' role in decision-making processes is often overlooked, and this interactional practice has rarely been systematically studied. Through a contextual narrative exploration of 42 naturally occurring consultations between patients (aged 22-84) and general practitioners (GPs) in England, we seek to fill this gap. By exploring how and why patients invoke third parties during discussions about medical treatments, who they refer to, what kind of knowledge their referents possess, and how GPs respond, our main aim is to capture the functions and implications of this interactional practice in relation to decision-making processes. Patients refer to third parties during decision-making processes in most of the consultations, usually to argue for and against certain treatment options, and the GPs recognise these utterances as pro-and-contra arguments. This enables patients to counter the GPs' professional knowledge through various knowledge-sources and encourage the GPs to target their specific concerns. By attributing arguments to third parties, patients claim decision-making influence without threatening the GPs' authority and expertise, which their disadvantaged epistemic position demands. Thereby, patients become able to negotiate their role and their epistemic position, to influence the agenda-setting, and to take part in the decision-making process, without being directly confrontational. Invoking third parties is a non-confrontational way of proposing and opposing treatment options that might facilitate successful patient participation in decision-making processes, and so limit the risk of patients being wronged in their capacity as knowers.
Collapse
Affiliation(s)
| | - Sarah Nettleton
- UiT The Arctic University of Norway, Norway
- University of York, UK
| | - Huw Grange
- UiT The Arctic University of Norway, Norway
| | | |
Collapse
|
2
|
Nilou FE, Christoffersen NB, Lian OS, Guassora AD, Broholm-Jørgensen M. Conceptualizing negotiation in the clinical encounter - A scoping review using principles from critical interpretive synthesis. PATIENT EDUCATION AND COUNSELING 2024; 121:108134. [PMID: 38199175 DOI: 10.1016/j.pec.2024.108134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/20/2023] [Accepted: 01/01/2024] [Indexed: 01/12/2024]
Abstract
OBJECTIVE Negotiation as an analytical concept in research about clinical encounters is vague. We aim to provide a conceptual synthesis of key characteristics of the process of negotiation in clinical encounters based on a scoping review. METHODS We conducted a scoping review of relevant literature in Embase, Psych Info, Global Health and SCOPUS. We included 25 studies from 1737 citations reviewed. RESULTS We found that the process of negotiation is socially situated depending on the individual patient and professional, a dynamic element of the interaction that may occur both tacitly and explicitly at all stages of the encounter and is not necessarily tied to a specific health problem. Hence, negotiation is complex and influenced by both social, biomedical, and temporal contexts. CONCLUSIONS We found that negotiation between patient and health professional occurs at all stages of the clinical encounter. Negotiation is influenced by social, temporal, and biomedical contexts that encompass the social meeting between patient and health professional. We suggest that health professionals strive to be attentive to patients' tacit negotiation practices. This will strengthen the recognition of the patients' actual wishes for their course of treatment which can thus guide the health professionals' recommendations and treatment.
Collapse
Affiliation(s)
- Freja Ekstrøm Nilou
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | | | - Olaug S Lian
- Department of Community Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Ann Dorrit Guassora
- Section and Research Unit of General Practice, University of Copenhagen, Denmark
| | | |
Collapse
|
3
|
Magnussen HJ, Kjeken I, Pinxsterhuis I, Sjøvold TA, Hennig T, Thorsen E, Feiring M. Participation in healthcare consultations: A qualitative study from the perspectives of persons diagnosed with hand osteoarthritis. Health Expect 2023; 26:1276-1286. [PMID: 36916677 PMCID: PMC10154812 DOI: 10.1111/hex.13744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/22/2023] [Accepted: 02/22/2023] [Indexed: 03/16/2023] Open
Abstract
INTRODUCTION Scarce health resources and differing views between persons with hand osteoarthritis (OA) and health professionals concerning care preferences contribute to sustaining a gap between actual needs and existing clinical guidelines for hand OA. The aim of this study is to explore the experiences of persons diagnosed with hand OA in their encounters with health services and how those experiences influence negotiations and decision-making in hand OA care. METHODS Data from 21 qualitative interviews with persons diagnosed with hand OA were collected, transcribed verbatim and analysed using reflexive thematic analysis. RESULTS Three main themes were developed: symptoms are perceived as ordinary ageing in everyday life, consultations are shaped by trust in healthcare and the responsibilities of prioritisation and self-care govern interactions. CONCLUSION Ideas of ageing, professional knowledge and self-management dominate hand OA health encounters and contribute to shaping illness perceptions, preferences and opportunities to negotiate decisions in consultations. PATIENT OR PUBLIC CONTRIBUTION Two patient research partners with hand OA are members of the study project group. One of them is also a co-author of this manuscript.
Collapse
Affiliation(s)
- Hege Johanne Magnussen
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway.,Norwegian National Advisory Unit on Rehabilitation in Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Ingvild Kjeken
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway.,Norwegian National Advisory Unit on Rehabilitation in Rheumatology, REMEDY, Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | - Irma Pinxsterhuis
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | | | | | - Eva Thorsen
- Lillehammer Rheumatism Hospital, Lillehammer, Norway
| | - Marte Feiring
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway.,Norwegian National Advisory Unit on Rehabilitation in Rheumatology, REMEDY, Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| |
Collapse
|
4
|
Lian OS, Nettleton S, Grange H, Dowrick C. 'It feels like my metabolism has shut down'. Negotiating interactional roles and epistemic positions in a primary care consultation. Health Expect 2022; 26:366-375. [PMID: 36385430 PMCID: PMC9854284 DOI: 10.1111/hex.13666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 10/07/2022] [Accepted: 11/06/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Our aim is to explore the ways in which a patient and a general practitioner (GP) negotiate knowledge claims stemming from different epistemic domains while dealing with a mismatch between experiential and biomedical knowledge during the clinical consultation. We interpret their interaction in relation to the sociocultural context in which their negotiation is embedded and identify factors facilitating their successful negotiation (a medical error is avoided). METHODS Based on a narrative analysis of a verbatim transcript of a complete naturally occurring primary care consultation, we explore the moment-to-moment unfolding of talk between the patient and the GP (two women). FINDINGS The patient experiences symptoms of what she interprets as a thyroid condition, and indirectly asks for medication. She presents her case by drawing on experiential knowledge ('it feels like my metabolism has shut down') and biomedical knowledge (while suggesting a diagnosis and a diagnostic test). The GP informs her that her thyroid blood tests are normal and uses biomedical knowledge to explain why she turns down the patient's request. This stages a potential conflict between the patient's embodied experiential knowledge and the doctor's biomedical knowledge. However, during their encounter, the patient and the GP manage to co-construct the patient's illness story and make shared decisions about further actions. CONCLUSION The transition from potential conflict to consensus is a result of the mutual efforts of two parties: a patient who persistently claims experiential as well as biomedical knowledge while at the same time deferring to the GP's professional knowledge, and a GP who maintains her epistemic authority while also acknowledging the patient's experiential and biomedical knowledge. PATIENT AND PUBLIC CONTRIBUTION Our empirical data are sourced from a data archive and patients were not involved in the design or conduct of the study, but our study is based on a naturally occurring clinical consultation with a patient.
Collapse
Affiliation(s)
- Olaug S. Lian
- Department of Community Medicine, Faculty of Health SciencesUiT—The Arctic University of NorwayTromsøNorway
| | | | - Huw Grange
- Department of Community Medicine, Faculty of Health SciencesUiT—The Arctic University of NorwayTromsøNorway
| | - Christopher Dowrick
- Department of Primary Care and Mental HealthUniversity of LiverpoolLiverpoolUK
| |
Collapse
|
5
|
Lian OS, Nettleton S, Grange H, Dowrick C. "I'm not the doctor; I'm just the patient": Patient agency and shared decision-making in naturally occurring primary care consultations. PATIENT EDUCATION AND COUNSELING 2022; 105:1996-2004. [PMID: 34887159 DOI: 10.1016/j.pec.2021.10.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/13/2021] [Accepted: 10/25/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To explore interactional processes in which clinical decisions are made in situ during medical consultations, particularly the ways in which patients show agency in decision-making processes by proposing and opposing actions, and which normative dimensions and role-expectations their engagement entail. METHODS Narrative analysis of verbatim transcripts of 22 naturally occurring consultations, sourced from a corpus of 212 consultations between general practitioners and patients in England. After thematically coding the whole dataset, we selected 22 consultations with particularly engaged patients for in-depth analysis. RESULTS Patients oppose further actions more often than they propose actions, and they oppose more directly than they propose. When they explain why they propose and oppose something, they reveal their values. Patients' role-performance changes throughout the consultations. CONCLUSION Assertive patients claim - and probably also achieve - most influence when they oppose actions directly and elaborate why. Patients display ambiguous role-expectations. In final concluding stages of decision-making processes, patients usually defer to GPs' authority. PRACTICE IMPLICATIONS Clinicians should be attentive to the ways in which patients want to engage in decision-making throughout the whole consultation, with awareness of normative dimensions of both process and content, and the ways in which patient's actions are constrained by their institutional position.
Collapse
Affiliation(s)
- Olaug S Lian
- Department of Community Medicine, University of Tromsø - The Arctic University of Norway, Tromsø, Norway.
| | | | - Huw Grange
- Department of Community Medicine, University of Tromsø - The Arctic University of Norway, Tromsø, Norway.
| | - Christopher Dowrick
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK.
| |
Collapse
|
6
|
Jepsen C, Lüchau EC, Assing Hvidt E, Grønning A. Healthcare in the hand: Patients’ use of handheld technology in video consultations with their general practitioner. Digit Health 2022; 8:20552076221104669. [PMID: 35694120 PMCID: PMC9178979 DOI: 10.1177/20552076221104669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 05/14/2022] [Indexed: 11/24/2022] Open
Abstract
Objective To analyse how the patient's use of handheld technology in video consultations with their general practitioner affects communication and the possibilities for the delivery of quality healthcare. Focusing on the visually communicated aspects of the video consultation, we present three episodes from our recordings of eight video consultations between Danish general practitioners and patients. Methods Using a multimodal social semiotic framework to conduct a micro-level analysis, we present episodes from our data in which the hardware's affordance of mobility gave rise to salient events in the interactions of patients who used handheld devices to carry out their video consultations. Results Patients’ use of technology plays a significant role in the interactions between general practitioner and patient and is thus an important factor to consider in how practice is shaped when using handheld video consultation technology. Conclusions Our findings demonstrate that the mobility of handheld devices (smartphone, tablet) can be used to augment sensing and embodiment and enhance the delivery of healthcare in video consultations. However, mobility may also disrupt the interaction. As a result, possibilities for the delivery of quality healthcare lie quite literally in the patients’ hands.
Collapse
Affiliation(s)
- Carole Jepsen
- Department for the Study of Culture, University of Southern Denmark, Odense, Denmark
| | - Elle Christine Lüchau
- Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Elisabeth Assing Hvidt
- Department for the Study of Culture, University of Southern Denmark, Odense, Denmark
- Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Anette Grønning
- Department for the Study of Culture, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
7
|
Negotiating uncertainty in clinical encounters: A narrative exploration of naturally occurring primary care consultations. Soc Sci Med 2021; 291:114467. [PMID: 34653685 DOI: 10.1016/j.socscimed.2021.114467] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 08/14/2021] [Accepted: 10/07/2021] [Indexed: 11/22/2022]
Abstract
Based on a narrative analysis of 20 naturally occurring clinical consultations between general practitioners and patients in England, sourced from the One in a million data archive, we explore how they conceptualize and negotiate medical and existential uncertainty. To capture the interactional element, which is often overlooked, three consultations receive special attention. While exploring the ongoing dynamics of the moment-to-moment realization of negotiations, we relate their actions to the institutionalized positions of doctor and patient. Situating their negotiations in the sociocultural context in which their interaction is embedded reveals how consultations unfold as a result of communication between two different positions in a normatively structured system. When uncertainty prevails, both patients and GPs mainly conceptualize uncertainty indirectly. By conceptualizing uncertainty indirectly and in a depersonalized manner, GPs manage to safeguard against clinical errors without compromising their authority and credibility. Contrary to medical uncertainty, which is continuously discussed, existential uncertainty usually recedes in the background. However, as our consultations unfold it becomes evident that medical and existential dimensions of uncertainty are inextricably linked. By acknowledging that clinical uncertainty is not only an epistemic concern but also an existential one, existential aspects may usefully rise to the surface.
Collapse
|
8
|
Feyereisen S, McConnell W, Thomas C, Puro N. Physician dominance in the 21st century: Examining the rise of non-physician autonomy through prevailing theoretical lenses. SOCIOLOGY OF HEALTH & ILLNESS 2021; 43:1867-1886. [PMID: 34435691 DOI: 10.1111/1467-9566.13366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 07/27/2021] [Accepted: 07/30/2021] [Indexed: 06/13/2023]
Abstract
Theories of physician dominance are a foundational contribution of medical sociology to the study of health care, but must be revisited in the light of ongoing changes in medicine. As non-physician specialists like nurse practitioners grow in number and acquire more autonomy, increasing medical profession differentiation presents a challenge for traditional physician dominance theories. After evaluating potential theoretical explanations for subordinate occupations' autonomy gains, we conduct a state-level quantitative analysis of variation in nursing policies across U.S. states. We construct our dependent variable, nursing autonomy, using seven state-level advanced practice nursing policies adopted from 2001-2017. Using an ordered scale, we code nurse practitioner, nurse anaesthetist, nurse midwife and clinical-nurse-specialist practice and prescription polices according to each policy's autonomy level. We then use time-series regression to examine theory-driven propositions regarding nursing autonomy change. Nursing autonomy has increased over time, signalling a general erosion of physician dominance. However, we find differential patterns of policy adoption, indicating that erosion is not uniform. Physicians have maintained dominance in relatively prestigious specialties (e.g. anaesthesiology) while dominance declined in others (e.g. obstetrician). Factors external to the profession, such as consumer power, continue to influence within-profession dynamics. Examining ongoing professional differentiation in medicine illustrates how physician dominance depends on shifting social and professional contexts.
Collapse
Affiliation(s)
- Scott Feyereisen
- College of Business, Florida Atlantic University, Boca Raton, Florida, USA
| | - William McConnell
- Dorothy F. Schmidt College of Arts and Letters, Florida Atlantic University, Boca Raton, Florida, USA
| | - Clayton Thomas
- Ivy College of Business, Iowa State University, Ames, Iowa, USA
| | - Neeraj Puro
- College of Business, Florida Atlantic University, Boca Raton, Florida, USA
| |
Collapse
|