Epistemic justice is the basis of shared decision making

BACKGROUND

There is little evidence that share decision-making (SDM) is being successfully implemented, with a significant gap between theory and clinical practice. In this article we look at SDM explicitly acknowledging its social and cultural situatedness and examine it as a set of practices (e.g. actions, such as communicating, referring, or prescribing, and decisions relating to them). We study clinicians' communicative performance as anchored in the context of professional and institutional practice and within the expected behavioural norms of actors situated in clinical encounters.

DISCUSSION

We propose to see conditions for shared decision-making in terms of epistemic justice, an explicit acknowledgment and acceptance of the legitimacy of healthcare users and their accounts and knowledges. We propose that shared decision-making is primarily a communicative encounter which requires both participants to have equal communicative rights. It is a process that is started by the clinician's decision and requires the suspension of their inherent interactional advantage.

CONCLUSION

The epistemic-justice perspective we adopt leads to at least three implications for clinical practices. First, clinical training must go beyond the development of communication skills and focus more on an understanding of healthcare as a set of social practices. Second, we suggest medicine develop a stronger relationship with humanities and the social sciences. Third, we advocate that shared decision-making has issues of justice, equity, and agency at its core.

Experience of the Absence of the Journey to Sessions in Clients' Narratives About Online Psychotherapy

Background

Remotely provided psychotherapy due to the COVID-19 pandemic became common. One of the most significant changes related to providing online psychotherapy services is that clients no longer travel to their sessions.

Aims

In the article we are interested in the narrated experience of the absence of journey to psychotherapy sessions. We study clients' stories of past journeys and how their absence, resulting from the change of the mode of therapy provision, is coped with and replaced by other activities in their narratives.

Methods

The study takes a constructionist approach to discourse and focuses on the lexico-grammatical form of the notes. The data come from 12 semi-structured interviews with people who declared attending remote psychotherapy sessions after the national lockdown had been introduced.

Results

In the collected data, the physical journey is constructed not only as travel time, solitude which can be used for reflection, but, importantly, as an active process which ends with a resolution. In contrast, in narratives of the time before an online session, constructions of unfettered agents are replaced with those of people whose actions are hedged and qualified.

Conclusion

We argue that in the informants' narratives the journey to psychotherapy is meaningful and is part of the therapeutic process. We propose that it is a time of passing between two states—one before therapy and one in session. The journey therefore is experienced as a process of change, and not only a process of traveling.

A three-talk model for shared decision making: multistage consultation process

Objectives To revise an existing three-talk model for learning how to achieve shared decision making, and to consult with relevant stakeholders to update and obtain wider engagement.Design Multistage consultation process.Setting Key informant group, communities of interest, and survey of clinical specialties.Participants 19 key informants, 153 member responses from multiple communities of interest, and 316 responses to an online survey from medically qualified clinicians from six specialties.Results After extended consultation over three iterations, we revised the three-talk model by making changes to one talk category, adding the need to elicit patient goals, providing a clear set of tasks for each talk category, and adding suggested scripts to illustrate each step. A new three-talk model of shared decision making is proposed, based on "team talk," "option talk," and "decision talk," to depict a process of collaboration and deliberation. Team talk places emphasis on the need to provide support to patients when they are made aware of choices, and to elicit their goals as a means of guiding decision making processes. Option talk refers to the task of comparing alternatives, using risk communication principles. Decision talk refers to the task of arriving at decisions that reflect the informed preferences of patients, guided by the experience and expertise of health professionals.Conclusions The revised three-talk model of shared decision making depicts conversational steps, initiated by providing support when introducing options, followed by strategies to compare and discuss trade-offs, before deliberation based on informed preferences.

Construction of suicidal ideation in medical records

In this article, the authors are interested in exploring discursive transformation of patients' stories of suicidal ideation into medical discourses. In other words, they focus on how the narrated experience of suicidal thoughts made during the psychiatric assessment interview is recorded in the patients' medical record. The authors' data come from recordings of psychiatric interviews, as well as the doctors' notes in the medical records made after the interviews, collected in psychiatric hospitals in Poland. Assuming a constructionist view of discourse, they demonstrate that lived experience of suicide ideation resulting in stories of a complex and homogeneous group of "thoughts" is reduced to brief statements of fact of presence/existence. Exploration of the relationship between the interviews and the notes suggest a stark imposition of the medical gaze upon them. The authors end with arguments that discursive practices relegating lived experience from the focus of clinical practice deprives it of information which is meaningful and clinically significant.

Context and goals: Suicide notes from a linguistic point of view

The article is a critique of a study of language of suicide notes. It raises the issue of the acontextual approach to language and suggests that suicide notes and their language must be seen within the social context in which they are written. Moreover, the article challenges the assumption that suicide notes have only a representational function. Instead, it argues that they can serve a host of other communicative purposes.

Organ donation agency: A discourse analysis of correspondence between donor and organ recipient families

Studies about the psychosocial issues concerning organ donation and transplantation tend to focus on the experiences of donor or recipient families. Little is known about the part played by correspondence exchanged between these two groups; in particular how they perceive the agency of organ donation. This is the first analysis to address the representation of the act of donation from the viewpoint of both donor and recipient families through interrogation of archived correspondence data, using linguistic techniques. The data was drawn from a collection of letters, from four USA organ procurement organisations, exchanged between donor and transplant recipient families. Donor families consistently linguistically ascribed agency and accountability for donation to the person who died, the donor. For the recipient families, on the other hand, the 'giver' was mainly implied, ambiguous or ascribed to the donor family.

Experience of suicidal thoughts: a discourse analytic study

In this paper we explore the relationship between current psychiatric thinking on suicide and service users' accounts of suicidal ideation and suicide attempts. The data comes from recordings of psychiatric interviews collected in three psychiatric hospitals in Poland. Assuming a constructionist view of discourse we argue that the literature on suicide ignores and simplifies the experience of those who think about suicide and attempt to commit it, and constructs their experiences as a homogeneous group of 'thoughts' with only limited content. We also offer a preliminary insight into the complexity of 'suicide thoughts', as narrated by those reporting them. We demonstrate that they are marginalized and made relatively irrelevant in the accounts of attempted suicide. Additionally, we demonstrate that while women construct suicide attempts (whether actually attempted in the end or not) as at least potentially beyond their control, men's narratives show them in control of the attempt, as if choosing an available option. We conclude by exploring possibilities of further qualitative discourse analytic research which builds on the findings we present here.

Identity ambivalence and embodiment in women's accounts of the gynaecological examination

In this article we are interested in the negotiation of identities in women's narratives of their gynaecological examination and more particularly, the shifts of identity positions that permeate their stories. Taking a constructionist view of discourse and identity, we make two arguments in the article. First, we demonstrate that women talking about their gynaecological examinations constructed their selves ambiguously. The identity spaces that they discursively opened in the narratives were not inhabited. Second, we show that the embodiment of their identities--the inclusion of the body into the construction of self--fluctuates depending on the stage of the narrative of the examination.

Gender and the gynecological examination: women's identities in doctors' narratives

The authors explore the constructions of gender in male doctors' narratives of gynecological examinations. Focusing on the ways in which gender identities are constructed in the stories of the medical encounter, they argue, first, that gender is more flexible during the visit with a gynecologist than has been suggested. Gendered identities are assumed and put aside as the interaction progresses, with its final stage--the pelvic examination--being constructed with gender removed. Second, they argue that undressing is invested with a special status during the examination. It is a gendered rite of passage between the two different ungendered subject positions of the doctor and the patient. They conclude that contrary to the assumptions in the literature on gynecological interactions, it is the genderization of undressing that is most conducive to securing the least face-threatening gynecological examination for the woman.