"I'm not the doctor; I'm just the patient": Patient agency and shared decision-making in naturally occurring primary care consultations

Negotiating uncertainties: care-seeking in an algorithmic society

This article examines how different layers of health-related uncertainties emerge and intersect in an algorithmic society. We aim to understand how people's self-care practices co-evolve with digitalised health systems. Sweden stands out among Western countries due to the population's high digital consumption of medical and health products. We conceptualise health-related uncertainties as inherent in care-seeking. The uncertainties are embedded in an algorithmic society and hinge on what we term algorithmised medicine. Methods used are open-ended questionnaires and semistructured interviews with Swedish residents. We identify: First, people are aware of algorithm-embedded digital infrastructure and its impact on information access in everyday life. Second, people oscillate on a trust-distrust nexus in different contexts. And third, lived experiences of the body compete with medical advice and online information. We conclude that while formal health systems strive to be robust, access to medicines remains an uncertain practice at the interplay of medicine, algorithms and bodily experiences of sickness. This study contributes to the field of medical humanities by showing that the digital arena is a porous and emergent entity, with inseparable links to people's lived experiences.

Proximity care pathways and digitalization: opportunities and concerns for medication safety management-Insights from the ProSafe study on community perspectives

Background

Establishing proximity care pathways, including the digitalization of healthcare, is valuable for sustainable management of Non-Communicable Diseases (NCDs) and Patient-Centered Care (PCC) promotion. However, new safety concerns, particularly in therapy management, may arise. The Community-Based Participatory Research (CBPR) "ProSafe" aims at (i) explore stakeholders' perspectives on medication safety management in proximity care and (ii) analyze which determinants affect the community's perspective.

Methods

A survey was co-developed with a Patient Safety Council (PSC) and the support of a pharmaceutical company. A purposeful sampling strategy was implemented to recruit individuals aged 18 and older. Data were collected using a dedicated online platform; differences between patients' and healthy people's perspectives were explored. Preliminary multiple regression analyses were performed to examine how sociodemographic factors, clinical data and level of digitalization affect outcomes using linear and probit models, accounting for the nature of each outcome variable. The models were combined into multiple equations using a Conditional Mixed Process (CMP) approach.

Results

417 individuals completed the survey (81.0% affected by a disease). A positive attitude towards shifting therapy administration from hospital to home setting was observed even if a significantly higher proportion of patients compared to healthy individuals raised concerns regarding a potential negative impact on the doctor-patient relationship (47.0% vs. 32.9%, p < 0.01). Additionally, 63.7% of patients reported they would feel less supported in the care process. The usefulness of telehealth, including tele-pharmacy for drug therapy management, was rated higher by healthy individuals compared to patients (mean value 1.3 vs. 1.5 p < 0.01); 43.9% of patients raised concerns regarding the excessive responsibility placed on them in digital care compared to traditional healthcare. Health status and level of education were the variables most frequently associated with significant impacts across multiple outcomes.

Conclusion

The community's perspective on the development of proximity care pathways provided valuable insights into concerns, fears, and limitations that could impact the effectiveness of this important shift in healthcare delivery. Effectively addressing these issues is essential to truly bring disease and medication management closer to patients and their living environments while ensuring that the community becomes co-creators in the implementation of proximity care, fostering health equity and patient autonomy.

Understanding access to general practice through the lens of candidacy: a critical review of the literature

BACKGROUND

Dominant conceptualisations of access to health care are limited, framed in terms of speed and supply. The Candidacy Framework offers a more comprehensive approach, identifying diverse influences on how access is accomplished.

AIM

To characterise how the Candidacy Framework can explain access to general practice - an increasingly fraught area of public debate and policy.

DESIGN AND SETTING

Qualitative review guided by the principles of critical interpretive synthesis.

METHOD

We conducted a literature review using an author-led approach, involving iterative analytically guided searches. Articles were eligible for inclusion if they related to the context of general practice, without geographical or time limitations. Key themes relating to access to general practice were extracted and synthesised using the Candidacy Framework.

RESULTS

A total of 229 articles were included in the final synthesis. The seven features identified in the original Candidacy Framework are highly salient to general practice. Using the lens of candidacy demonstrates that access to general practice is subject to multiple influences that are highly dynamic, contingent, and subject to constant negotiation. These influences are socioeconomically and institutionally patterned, creating risks to access for some groups. This analysis enables understanding of the barriers to access that may exist, even though general practice in the UK is free at the point of care, but also demonstrates that a Candidacy Framework specific to this setting is needed.

CONCLUSION

The Candidacy Framework has considerable value as a way of understanding access to general practice, offering new insights for policy and practice. The original framework would benefit from further customisation for the distinctive setting of general practice.

Conceptualizing negotiation in the clinical encounter - A scoping review using principles from critical interpretive synthesis

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.

Who really decides? Feeding decisions 'made' by caregivers of children with cerebral palsy

BACKGROUND

 There are no definitive guidelines for clinical decisions for children with cerebral palsy (CP) requiring enteral feeds. Traditionally, medical doctors made enteral feeding decisions, while patients were essentially treated passively within a paternalistic 'doctor knows best' approach. Although a more collaborative approach to decision-making has been promoted globally as the favoured model among healthcare professionals, little is known about how these decisions are currently made practically.

OBJECTIVES

 This study aimed to identify the significant individuals, factors and views involved in the enteral feeding decision-making process for caregivers of children with CP within the South African public healthcare sector.

METHOD

 A single-case research design was used in this qualitative explorative study. Data were collected using semi-structured interviews and analysed using reflexive thematic analysis.

RESULTS

 Four primary individuals were identified by the caregivers in the decision-making process: doctors, speech therapists, caregivers' families and God. Four factors were identified as extrinsically motivating: (1) physiological factors, (2) nutritional factors, (3) financial factors and (4) environmental factors. Two views were identified as intrinsically motivating: personal beliefs regarding enteral feeding tubes, and feelings of fear and isolation.

CONCLUSION

 Enteral feeding decision-making within the South African public healthcare sector is currently still dominated by a paternalistic approach, endorsed by a lack of caregiver knowledge, distinct patient-healthcare provider power imbalances and prescriptive multidisciplinary healthcare dialogues.Contribution: This study has implications for clinical practice, curriculum development at higher education training facilities, and institutional policy changes and development, thereby contributing to the current knowledge and clinical gap(s) in the area.

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.

'It feels like my metabolism has shut down'. Negotiating interactional roles and epistemic positions in a primary care consultation

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.