Video analysis of communication by physiotherapists and patients in video consultations: a qualitative study using conversation analysis

OBJECTIVES

To investigate the challenges of doing physical examinations and exercises by video, and the communication strategies used by physiotherapists and patients to overcome them.

DESIGN

A qualitative study of talk and social actions, examining the verbal and non-verbal communication practices used by patients and physiotherapists. Video consultations between physiotherapists and patients were video recorded using MS Teams, transcribed and analysed in detail using Conversation Analysis.

SETTING

Video consultations were recorded in three specialist settings (long-term pain, orthopaedics, and neuromuscular rehabilitation) across two NHS hospitals.

PARTICIPANTS

15 adult patients (10 female, 5 male; aged 20-77) with a scheduled video consultation.

RESULTS

Examinations and exercises retain-->were successfully accomplished in all 15 consultations. Two key challenges were identified for physiotherapists and patients when doing video assessments: (1) managing safety and clinical risk, and (2) making exercises and movements visible. Challenges were addressed by through communication practices that were patient-centred and tailored to the video context (e.g., explaining how to frame the body to the camera or adjust the camera to make the body visible).

CONCLUSIONS

Video is being used by physiotherapists to consult with their patients. This can work well, but tailored communication strategies are critical to help participants overcome the challenges of remote physical examinations and exercises.

CONTRIBUTION OF THE PAPER

This paper is a first to use video-based analysis to determine the challenges of video consulting for doing remote assessments and exercises in physiotherapy settings. It demonstrates how patients and physiotherapists use communication strategies to raise concerns around safety and visibility and how they overcome these concerns.

A clinical assessment of three-dimensional-printed liver model navigation for thrice or more repeated hepatectomy based on a conversation analysis

PURPOSES

We performed a conversation analysis of the speech conducted among the surgical team during three-dimensional (3D)-printed liver model navigation for thrice or more repeated hepatectomy (TMRH).

METHODS

Seventeen patients underwent 3D-printed liver navigation surgery for TMRH. After transcription of the utterances recorded during surgery, the transcribed utterances were coded by the utterer, utterance object, utterance content, sensor, and surgical process during conversation. We then analyzed the utterances and clarified the association between the surgical process and conversation through the intraoperative reference of the 3D-printed liver.

RESULTS

In total, 130 conversations including 1648 segments were recorded. Utterance coding showed that the operator/assistant, 3D-printed liver/real liver, fact check (F)/plan check (Pc), visual check/tactile check, and confirmation of planned resection or preservation target (T)/confirmation of planned or ongoing resection line (L) accounted for 791/857, 885/763, 1148/500, 1208/440, and 1304/344 segments, respectively. The utterance's proportions of assistants, F, F of T on 3D-printed liver, F of T on real liver, and Pc of L on 3D-printed liver were significantly higher during non-expert surgeries than during expert surgeries. Confirming the surgical process with both 3D-printed liver and real liver and performing planning using a 3D-printed liver facilitates the safe implementation of TMRH, regardless of the surgeon's experience.

CONCLUSIONS

The present study, using a unique conversation analysis, provided the first evidence for the clinical value of 3D-printed liver for TMRH for anatomical guidance of non-expert surgeons.

Investigating question-answer sequences in child mental health assessments: Engaging children and families through declarative question design

OBJECTIVE

In mental health settings, before a child can be diagnosed with a mental health condition, they must initially be assessed. These assessments are characterised by question-answer sequences with the child and family members, and our objective is to explore the function of declarative questions.

METHODS

Video recordings of mental health assessments from 28 families were collected, each being approximately 90 min. Referred children were aged 6-17-years. Data were transcribed using the Jefferson approach and conversation analysis was used.

RESULTS

Attention to question-answer sequences identified that one common type was the declarative question. We focus on three identifiable forms: clean language short declaratives, declaratives with extreme case formulations, and reformulation declaratives.

CONCLUSIONS

The response to these three types of declaratives formed the basis for subsequent question-answer elaboration sequences. The question functioned both to engage the child directly and align with other family members.

PRACTICE IMPLICATIONS

Implications for practitioners are that these types of declarative questions offer a resource to engage in fact-checking in a way that is non-face-threatening. Conversation analysis provides a methodological tool for practitioners to engage in reflective practice to enhance their clinical skills in relation to question design.

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.

"Are you otherwise fit and well?": Past medical history questions in UK paediatric consultations

Accurate diagnosis and treatment depend upon detailed knowledge of both the child's presenting symptoms and their past medical history. However, the process of soliciting past medical history has never been subject to systematic scrutiny in actual clinical practice.

OBJECTIVE

To examine the function of the question "are you otherwise fit and well?" to elicit a child's general medical history in UK paediatric allergy outpatient consultations.

METHODS

Examination of 30 video-recorded UK paediatric outpatient consultations involving children (2-10 years), caregivers, and one doctor. We identified, transcribed, and interrogated 13 examples, deploying the systematic and rigorous method of conversation analysis to elucidate the question's micro-design elements and their consequences for the consultation's trajectory.

RESULTS

Asking "Are you otherwise fit and well?" is built to efficiently solicit a problem-free report of good health. Nonetheless patients can and do raise other relevant matters. In practice, the question initiates several interactional matters simultaneously: establishing/resolving (mis)understandings of "fitness" and "wellness"; negotiating opportunities for children's participation; and importantly, a shift towards discussing more general wellbeing.

CONCLUSION

Past medical history questions unavoidably generate broader interactional matters which are skilfully resolved in real-time between clinicians, caregivers, and children.

PRACTICE IMPLICATIONS

Clinical training could be greatly enhanced by integrating insights into the interactional consequences of asking questions, particularly in the complex multiparty environment of paediatrics. While the question 'Are you otherwise fit and well' clearly serves an important function, clinicians should be alert to the possible problems it might raise, especially when directed towards younger children.

Responsibility to report symptoms: Pursuing symptom reports from children in pediatric encounters

OBJECTIVE

The paper focuses on cases in which children disconfirm a symptom previously reported by their parents and analyzes how doctors and parents continue asking questions to elicit symptom confirmation from children.

METHODS

The study employs Conversation Analysis (CA) to examine 50 video recordings of Russian-language pediatric consultations with 4 pediatricians and approximately 50 children.

RESULTS

The findings indicate two strategies used by participants to pursue symptom confirmation. First, calibrating question design via changing the questions' format and narrowing the questions' topical agenda to specify what kind of information is expected from the child. Second, changing the questions' format (from content to polar) without adjusting the topical agenda.

CONCLUSION

The paper argues that engaging children in medical consultations might be challenging because they do not orient to, and so do not perform a responsibility that is institutionally expected from patients, in particular, reporting medically-relevant information.

PRACTICE IMPLICATIONS

The analysis shows that using polar questions about everyday activities and experiences relevant to the child and pursuing symptom reports by gradually narrowing down the questions' topical agenda can be an effective way to secure medically-relevant information.

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.

Keeping the conversation going: How progressivity is prioritised in co-remembering talk between couples impacted by dementia

This article explores how partners keep the conversation going with people living with dementia (PLWD) when speaking about shared memories. Remembering is important for PLWD and their families. Indeed, memory loss is often equated with identity loss. In conversation, references to shared past events (co-rememberings) can occasion interactional trouble if memories cannot be mutually recalled. This article analyses partners' interactional practices that enable progressivity in conversations about shared memories with a PLWD. In previous research, both informal and formal carers have reported that they can find interacting with PLWD difficult. Identifying practices used by partners is one way to begin addressing those difficulties. Analytical findings are based on over 26 hours of video data from domestic settings where partners have recorded their interactions with their spouse/close friend who is living with dementia. The focus is on 14 sequences of conversation about shared memories. We show how particular practices (candidate answers, tag questions and single-party memory of a shared event) structure the interaction to facilitate conversational progression. When partners facilitate conversational progressivity, PLWD are less likely to experience stalls in conversation. Our findings suggest the actual recall of memory is less relevant than the sense of shared connection resulting from the conversational activity of co-remembering, aiding maintenance of individual and shared identities. These findings have relevance for wider care settings.

When patients demur: Resisting diagnostic closure in US primary care

Patients are more engaged in their healthcare than ever before, including in the process of diagnostic sensemaking. But in acute primary care encounters, the interactional flow of the visit is shaped by an orientation toward the physician as the authority over diagnostic reasoning. Once physicians close diagnostic inquiry and transition into counseling, their assessment - and the extent to which it converges with the patient's perspective - comes into full view. Yet this is precisely when patients have reduced occasions to speak up if they do have concerns, as the "train has left the station" both diagnostically and interactionally. Using conversation analysis and a dataset of 75 video recordings of acute primary care encounters in the US, this article examines how patients speak up in this constrained environment. The concept of diagnosis demurral is proposed to describe how patients resist diagnostic closure by renewing the relevance of diagnostic inquiry, either in response to a diagnosis or at any point following the transition into counseling. Findings suggest that patients demur more frequently than prior studies on diagnosis resistance may have predicted, but they do so in ways that maintain deference to the physician's authority over matters of diagnosis: speaking up primarily outside the diagnostic moment, relying on actions in their own domain of expertise (e.g., their illness experience), and working to additionally soften the epistemic and interactional inappositeness of their demurral. This behavior sits at the nexus of two opposing forces: patients may be more engaged, but their participation is constrained by a continued legacy of medical authority over diagnosis, to which patients themselves continue to respond and reproduce.

Metaphoric language in the differential diagnosis of epilepsy and psychogenic non-epileptic seizures: Time to move forward

Conversation analysis (CA) to identify metaphoric language (ML) has been proposed as a tool for the differential diagnosis of epileptic (ES) and psychogenic nonepileptic seizures (PNES). However, the clinical relevance of metaphoric conceptualizations is not clearly defined. The current study aims to investigate the ML utilized by individuals with ES and PNES in a pulled multi-country sample. Two blinded researchers examined the transcripts and videos of 54 interviews of individuals (n = 29, Italy; n = 11, USA; n = 14, Russia) with ES and PNES, identifying the patient-seizure relationship representative of the patient's internal experience. The diagnoses were based on video-EEG. Metaphors were classified as "Space/place", "External force", "Voluntary action", and "Other". A total of 175 metaphors were identified. No differences between individuals with ES and PNES were found in metaphoric occurrence (χ2 (1, N = 54) = 0.07; p = 0.74). No differences were identified when comparing the types of metaphors utilized by participants with ES and those with PNES. Patients with PNES and ES did not demonstrate differences in terms of occurrence and categories in ML. Therefore, researchers and clinicians should carefully consider the use of metaphor conceptualizations for diagnostic purposes.

Companion responses to diagnosis in Chinese outpatient clinical interaction

Patients regularly attend clinical consultations with companions in Chinese outpatient clinics. Despite companions' significant influence on clinical consultations, how companions respond to diagnosis and their contributions to the activity of diagnosis in Chinese outpatient clinical interaction remain under-researched. The present study, by adopting the method of conversation analysis, investigated clinicians' diagnostic deliveries and companions' subsequent responses in Chinese outpatient clinical interaction. The data for this study consisted of 79 video recordings of clinical consultations in the Chinese orthopedic outpatient clinic, approximately lasting 12 h and involving three male clinicians, 79 patients (37 male/42 female), and 91 companions (51 male/40 female). Three basic categories of companion responses to diagnosis were identified: minimal verbal responses, embodied responses, and extended responses. It was demonstrated that these distinct responses allowed companions to challenge clinicians' medical authority in the activity of diagnosis by delivering their own diagnostic judgments, resisting clinicians' diagnoses, and orienting to clinicians' accounts for their diagnostic statements and reasoning, thus displaying companion agency in the Chinese outpatient clinical decision-making and indicating a transition from a paternalistic model to a family-centered model of the doctor-patient relationship in the Chinese orthopedic outpatient interaction. This study furthers current knowledge of companion involvement across healthcare contexts and contributes to raising clinicians' awareness of the significance of companions' contributions in Chinese outpatient clinical interaction.

Storytelling and affiliation between healthcare staff in Schwartz Round interactions: A conversation analytic study

It is well known that the demands of working in healthcare can take a psychological toll on staff. Schwartz Centre Rounds are an intervention aimed at supporting staff wellbeing through providing a forum to talk about the emotional, social and ethical complexities of such work, employing facilitated storytelling and group discussion to try and achieve this. However, while prior research, through extensive interviews and surveys, has found Schwartz Rounds to be effective in fostering compassion and wellbeing amongst participants, the talk that occurs within Schwartz Rounds themselves has not been explored. One mechanism that has been considered in how Schwartz Rounds function is the creation of a 'counter-cultural', conversational space, suggesting the nature of the interactions themselves may be important in achieving their beneficial effects. Using conversation analytic (CA) methods, we examine Schwartz Rounds in the UK to address, at a detailed micro-level, how sequences of talk work to accomplish the key aims of this setting. Five separate one-hour Schwartz Rounds were recorded across three UK hospital Trusts, between January 2019 and February 2020. Our analysis addresses how panellists tell their stories in a way that emphasises the uniqueness of their experience but also provides a generalisable emotional 'upshot' and 'stance' for the audience to later respond to. We then focus in on how audience members are able to respond to these stories affiliatively, offering endorsements, generalisations and second stories. Drawing on prior CA literature examining support groups and psychotherapy, we consider how the format of Schwarz Rounds creates important opportunities for interpersonal affiliation in this context. Considering these interactional features alongside other research findings on Schwartz Rounds, we discuss how opportunities for interactional affiliation may be central to their success, with implications for how these interactions can be best facilitated.

An Applied Linguistics Study of How Students Prevent Embarrassments and Impositions During Interactive Examination OSCEs

OBJECTIVE

To assess the effectiveness of politeness strategies used by pharmacy students to avoid embarrassing or imposing on others during objective structured clinical examinations.

METHODS

A total of 19 objective structured clinical examinations video recordings of 10 students (participants) interacting with mock patients were examined using the framework of Politeness Theory (PT). All relevant participant acts (speech activities) were coded using PT into (1) type of face threatening acts (ie, potentially sensitive situations-as regarded by PT) and (2) politeness strategies used to mitigate them. Conversation Analysis was then used to examine the effectiveness of conversational strategies by judging the 'patient' responses to these strategies.

RESULTS

Most acts had the potential to impact patients' negative face needs (ie, desire to act autonomously, eg, upon the practitioner making a request), positive face needs (ie, desire to be liked, eg, upon the practitioner making a diagnosis), or both. Despite applying a variety of positive politeness strategies (eg, avoiding disagreement, or expressing understanding) to prevent embarrassment to the patient, and negative politeness strategies (eg, being indirect, using hedging, or minimizing the imposition) to avoid directly imposing on them, "dispreferred responses" showed participants mostly focused on avoiding impositions, corresponding to what they have been taught, rather embarrassments.

CONCLUSION

Participants were less aware that discussing sensitive topics could cause embarrassment to patients, with the potential to upset them. Developing teaching and evaluation methods to consider patients' face needs could help in assessing and improving pharmacy students' communication skills.

Uncertainty in complex healthcare settings - The need for a comprehensive approach

Uncertainty is increasingly recognized as a crucial phenomenon throughout medical practice. Research on uncertainty so far has been scattered across disciplines, leading to a lack of consensus about what uncertainty represents and minimal integration of knowledge obtained within isolated disciplines. Currently, a comprehensive view of uncertainty which does justice to normatively or interactionally challenging healthcare settings is lacking. This impedes research teasing apart when and how uncertainty manifests, how all stakeholders experience and value it, and how it affects medical communication and decision-making. In this paper, we argue that we need a more integrated understanding of uncertainty. We illustrate our argument using the context of adolescent transgender care, in which uncertainty occurs in myriad ways. We first sketch how theories of uncertainty have emerged from isolated disciplines, leading to a lack of conceptual integration. Subsequently, we emphasize why it is problematic that no comprehensive approach to uncertainty has yet been developed, using examples from adolescent transgender care. Finally, we advocate an integrated approach of uncertainty to further advance empirical research and to ultimately benefit clinical practice.

Shared decision-making during prostate cancer consultations: Implications of clinician misalignment with patient and partner preferences

Concepts of patient-centredness and shared decision-making inform expectations that clinicians should display sensitivity to patients' expressed preferences. This study examines the organisation of treatment-related preferences expressed by patients and their partners during clinical consultations for people with localised prostate cancer. A conversation analysis of twenty-eight diagnosis and treatment consultations was conducted with data recorded from four clinical sites across England. When clinicians disaligned from expressions of preference such as directing talk away from expressions, or moving to redress perceived misunderstandings, it caused discordance in the unfolding interaction. This led to couples silencing themselves. Two deviant cases were identified that did not feature the misalignment found in all other collected cases. In these two cases, the interaction remained collaborative. These findings highlight the immediate consequences of expressions of preference being resisted, rejected, and dismissed in a context where clinicians are expected to explore expressed preferences in service of SDM. The deviant case analysis offers an alternative practice to the pattern observed across the collection, offering a comparison between misaligned sequences, and cases where social solidarity was maintained. By acknowledging couple's expressions as valid contributions, rather than acting to inform or correct them, clinicians can create opportunity spaces for discussion around treatment preferences.

Displaying concerns within telephone triage conversations of callers with chest discomfort in out-of-hours primary care: A conversation analytic study

OBJECTIVES

In primary care out of hours service (OHS-PC), triage nurses ask questions to assign urgency level for medical assessment. A semi-automatic decision tool (the Netherlands Triage Standard, NTS) facilitates triage nurses with key questions, but does not leave much room for paying attention to callers' concerns. We wanted to understand how callers with chest pain formulate their concerns and are helped further during telephone triage.

METHODS

We conducted a conversation analytic study of 68 triage calls from callers with chest discomfort who contacted OHS-PC of which we selected 35 transcripts in which concerns were raised. We analyzed expressions of concerns and the corresponding triage nurse response.

RESULTS

Due to the task-oriented nature of the NTS, callers' concerns were overlooked. For callers, however, discussing concerns was relevant, stressed by the finding that the majority of callers with chest discomfort expressed concerns.

CONCLUSIONS

Interactional difficulties in concern-related discussions arised directly after expressed concerns if not handled adequately, or during the switch to the counseling phase.

PRACTICE IMPLICATIONS

When callers display concerns during telephone triage, we recommend triage nurses to explore them briefly and then return to the sequence of tasks described in the NTS-assisted triage process.

Enabling people living with dementia to make choices during creative workshops: a conversation analysis study of co-creativity, choice-sequences, and the supportive actions of carers

PURPOSE

Creative workshops can promote various positive outcomes for people with dementia, such as reductions in undesirable symptoms and achieving levels of autonomy. Although these are undoubtedly positive outcomes, there is little understanding of the specific processes that can enable such outcomes. To address this issue, our study investigates the interactional processes of "choice-sequences," in which a PlwD makes a choice pertaining to materials (e.g. pens, coloured papers) for a creative activity.

METHODS

This Conversation Analysis study draws upon around 60 hours of video-recorded creative workshops involving artists, people with dementia, and carers. Drawing upon the notion of "co-creativity," we examine the collaborative work that goes into accomplishing choice- sequences.

RESULTS

While these sequences typically begin with an artist presenting a choice to a PlwD, carers routinely enter these interactions and provide various forms of support needed to accomplish each basic action of a choice-sequence.

CONCLUSIONS

This study shows carers working alongside the artist to pursue the PlwD's choice in a triadic participation framework, and carers supporting the PlwD in a dyadic participation framework with the artist having exited the interaction. In providing such support, carers can utilize their understandings of the communicative norms and requirements of the PlwD.

Speaking out of turn: Implications of partner contributions for patient autonomy during prostate cancer consultations

OBJECTIVE

This research examines how partners contribute to clinical consultations for people with prostate cancer. It highlights a social practice where a partner responds to talk that addresses a patient.

METHODS

A conversation analysis of twenty-eight prostate cancer treatment and diagnostic consultations was carried out using data collected from four clinical sites across England.

RESULTS

The analysis demonstrated that this practice was prosocial and patient enabling. Partners oriented to the patient's primary rights to take their turn as the selected next speaker, only initiating after a substantial delay from the clinician's turn-at-talk. Consequently, the partner consistently opened an opportunity space that the patient took to elaborate upon, or collaborate with the partners' turn as they regularly took up a unified stance resisting the individualised configuration of the encounter.

CONCLUSION

This research highlights the social and clinical utility of partners during these consultations, as they served as important, yet underutilised interactional and informational resources for clinicians and patients.

PRACTICE IMPLICATIONS

This research indicates a need to reconsider the configuration of these consultations and sanction partners as formal participants. Absent of this, partners will continue to have to work to insert their contributions into consultations while resisting the dyadic structure of these interactions.

Discussing diet, nutrition, and body weight after treatment for gynecological cancer: a conversation analytic study of outpatient consultations

PURPOSE

To generate direct observational evidence for understanding how diet, nutrition, and weight-related topics are discussed during follow-up after treatment for gynecological cancer, as recommended by survivorship care guidelines.

METHODS

Conversation analysis of 30 audio-recorded outpatient consultations, involving 4 gyne-oncologists, 30 women who had completed treatment for ovarian or endometrial cancer, and 11 family members/friends.

RESULTS

From 21 instances in 18 consultations, diet, nutrition, or weight-related talk continued beyond initiation if the issue raised was ostensibly relevant to the clinical activity being undertaken at the time. These instances led to care-related outcomes (i.e., general dietary recommendations, referral to support, behavior change counseling) only when the patient identified needing further support. Diet, nutrition, or weight-related talk was not continued by the clinician if it was not apparently related to the current clinical activity.

CONCLUSIONS

The continuation of diet, nutrition, or weight-related talk during outpatient consultations after treatment for gynecological cancer, and the subsequent delivery of care-related outcomes, depends on its immediate clinical relevance and the patient indicating needing further support. The contingent nature of these discussions means there can be missed opportunities for the provision of dietary information and support post-treatment.

IMPLICATIONS FOR CANCER SURVIVORS

If seeking information or support for diet, nutrition, or weight-related issues post-treatment, cancer survivors may need to be explicit regarding their need for this during outpatient follow-up. Additional avenues for dietary needs assessment and referral should be considered to optimize the consistent delivery of diet, nutrition, and weight-related information and support after treatment for gynecological cancer.

"For Example" Formulations and the Interactional Work of Exemplification

Members in society make ubiquitous use of examples as a resource to engage in their everyday and specialized activities. This paper takes the resourcefulness of exemplification as a topic of inquiry by focusing on the formulative phrase "for example," investigating its interactional work within the analytic framework of ethnomethodology and conversation analysis. The data used consists of 11 h of video-recordings of English as a Foreign Language classroom lessons over a semester. We conceptualize exemplification as a holistic configuration (gestalt) where its work consists in the production and recognition of a pair, namely the exemplifying component and the exemplified component. We demonstrate how the teacher and students position the formulative phrase as a recognizable practice for the organization of two distinct actions: accounting for one's opinion and confirming an understanding. Our findings also present the different forms of exemplification, including elaborate narrative constructions, single terms or phrases, and specimen performances.

Talking delicately: Providing opportunistic weight loss advice to people living with obesity

Obesity is a major worldwide public health problem. Clinicians are asked to communicate public health messages, including encouraging and supporting weight loss, during consultations with patients living with obesity. However, research shows that talking about weight with patients rarely happens and both parties find it difficult to initiate. Current guidelines on how to have such conversations do not include evidence-based examples of what to say, when to say it and how to avoid causing offence (a key concern for clinicians). To address this gap, we examined 237 audio recorded consultations between clinicians and patients living with obesity in the UK in which weight was discussed opportunistically. Conversation analysis revealed that framing advice as depersonalised generic information was one strategy clinicians used when initiating discussions. This contrasted to clinicians who made advice clearly relevant and personalised to the patient by first appraising their weight. However not all personalised forms of advice worked equally well. Clinicians who spoke delicately when personalising the discussion avoided the types of patient resistance that we found when clinicians were less delicate. More delicate approaches included forecasting upcoming discussion of weight along with delicacy markers in talk (e.g. strategic use of hesitation). Our findings suggest that clinicians should not avoid talking about a patient's weight, but should speak delicately to help maintain good relationships with patients. The findings also demonstrate the need to examine communication practices to develop better and specific guidance for clinicians. Data are in British English.

"I was gonna ask you": How patients use agency framing to display engagement in primary care

The message that patients should be responsible for their health is pervasive. Health promotion campaigns encourage patients to "ask your doctor" about potential illnesses and treatments, preventive medicine guidelines call for patients to self-monitor to avoid future health problems, and models like shared decision-making advocate for greater patient involvement in medical decisions. Research shows that patients can participate in medical dialogue by asking questions, but that doing so is difficult due to the structure and social norms of medical visits. In this article, we ask: how can patients participate more actively in medical care? Drawing on video recordings of older patients (aged 65 and older) and primary care physicians, we use conversation analysis to describe one practice that patients use to demonstrate personal responsibility for their health; agency framing. This involves prefacing questions to the doctor with phrases that project a prior intended action, such as "I was gonna ask you", "I was gonna tell you" or "I wanted to ask you". Patients use agency framing to cast their questions as 1) independently motivated, 2) well-informed, and 3) personally responsible. Consequently, patients exert agency within the confines of the medical visit structure to resist the potential interpretation that their question was responsive to the doctor or to the local interactional context. Rather, agency framing allows patients to show that their question was considered independently. Questions designed with agency framing work to portray the speaker as a responsible patient who is not only meeting the bare minimum of expected health maintenance, but is staying ahead of medical problems. This article discusses the particular importance of this practice among older patients, for whom demonstrating a willingness and ability to cope with medical problems may be significant for maintaining independence.

Introducing the C-reactive protein point-of-care test: A conversation analytic study of primary care consultations for respiratory tract infection

The C-reactive protein point-of-care test (CRP-POCT) can help distinguish between viral and bacterial infection and has been promoted as a strategy to improve antimicrobial stewardship. The test is widely used in Sweden. National guidelines advocate conservative use in primary care consultations with patients presenting with symptoms of respiratory tract infection (RTI). Previous research suggests low adherence to guidelines. We provide new insights into the communication surrounding the CRP-POCT by documenting how the decision to administer the test is interactionally motivated and organized in Swedish primary care. The data consists of video-recordings of RTI-consultations. A CRP-POCT was performed in nearly two thirds of the consultations and our study is focused on a subset where the test is ordered by a medical doctor. We find that doctors order the test during the transition from or after physical examination, a practice that aligns with national guidelines. Guidelines indicate that pathological findings from physical examination are warrants for ordering the test but we only found one example where this was communicated to the patient. A more prevalent pattern was that doctors ordered the CRP-POCT even though the outcome of the physical examination was assessed as normal. Our analyses of these show that doctors can provide the rationale for ordering the test in subtle ways and that failure to provide a rationale is treated as a noticeable absence. We also find that the CRP-POCT can be used to reconcile the contrast between the normal physical examination and the patient's problem presentation. Doctors can also order the test in ways that position the CRP-POCT as criterial for antibiotic prescription. Consultations where the patients described the symptoms as particularly severe and/or persistent were more likely to engender elaborate accounts than consultations where patients presented their symptoms as less problematic.

Brief opportunistic interventions by general practitioners to promote smoking cessation: A conversation analytic study

Very brief opportunistic interventions for smoking cessation are effective, cost-saving for health systems, and universally recommended in guidelines. However, evidence suggests that clinicians are reluctant to intervene, citing interactional difficulties. Only one UK study has specifically examined smoking discussions, within naturally occurring primary care consultations. However smoking cessation treatment was not available at the time. We examined existing datasets amounting to 519 video-recordings of GP consultations in England for instances of talk about smoking. We used conversation analytic methods to assess patients' responses to doctors asking about smoking, giving advice on smoking, and offering cessation treatment. In 31 recordings it was apparent that the patient smoked, and, in 25/31 consultations, doctors initiated the topic of smoking. They did so by asking about smoking status, commonly during the history-taking phase of the consultation. In many instances, these questions led to active resistance from patients against being placed in a discreditable category, for example by minimising their smoking. This was more pronounced when GPs pursued efforts to quantify the amount smoked. Thereafter, where doctors returned to the topic of smoking, they did so typically by linking smoking to the patient's medical condition, which likewise led to resistance. Guidance recommends that GPs advise on how best to quit smoking where patients are interested in doing so, but this was only evident in a minority of consultations. Where GPs offered support for cessation, they did so using interactional practices that minimised the need for the patient to respond and thereby accept. Interactional difficulties were found to be common in consultations between GPs and people who smoke when GPs actions aligned with some VBA guidelines. Future research should examine when and how advice on how best to quit, and offers of support, should be delivered within primary care consultations.

When and how teachers intervene in group discussions on experiences from practice in postgraduate medical education: an interactional analysis

Medical educators constantly make decisions on when and how to intervene. Current literature provides general suggestions about types of teacher interventions. Our study aims to specify that knowledge by describing in detail the actions teachers do when intervening, the interactional consequences of those actions, and how these relate to teacher roles in group discussions. We collected all first teacher interventions (n = 142) in 41 videorecorded group discussions on experiences from practice at the Dutch postgraduate training for General Practice. We analyzed the interventions using Conversation Analysis. First, we described the timing, manner, actions, and interactional consequences of each intervention. Next, we inductively categorized actions into types of actions. Finally, we analyzed the distribution of these types of actions over the group discussion phases (telling, exploration, discussion, conclusion). First teacher interventions were done at observably critical moments. Actions done by these interventions could be categorized as moderating, expert, and evaluating actions. Moderating actions, commonly done during the telling and exploration phase, are least directive. Expert and evaluator actions, more common in the discussion phase, are normative and thus more directive. The placement and form of the actions done by teachers, as well as their accounts for doing those, may hint at a teacher orientation to intervene as late as possible. Since the interventions are occasioned by prior interaction and responded to in different ways by residents, they are a collaborative interactional accomplishment. Our detailed description of how, when and with what effect teachers intervene provides authentic material for teacher training.

Decision-making ethics in regards to life-sustaining interventions: when physicians refer to what other patients decide

BACKGROUND

Health decisions occur in a context with omnipresent social influences. Information concerning what other patients decide may present certain interventions as more desirable than others.

OBJECTIVES

To explore how physicians refer to what other people decide in conversations about the relevancy of cardio-pulmonary resuscitation (CPR) or do-not-attempt-resuscitation orders (DNAR).

METHODS

We recorded forty-three physician-patient admission interviews taking place in a hospital in French-speaking Switzerland, during which CPR is discussed. Data was analysed with conversation analysis.

RESULTS

Reference to what other people decide in regards to CPR is used five times, through reported speech. The reference is generic, and employed as a resource to deal with trouble encountered with the patient's preference, either because it is absent or potentially incompatible with the medical recommendation. In our data, it is a way for physicians to present decisional paths and to steer towards the relevancy of DNAR orders ("Patients tell us 'no futile care'"). By calling out to a sense of membership, it builds towards the patient embracing norms that are associated with a desirable or relevant social group.

CONCLUSIONS

Introducing DNAR decisions in terms of what other people opt for is a way for physicians to bring up the eventuality of allowing natural death in a less overt way. Formulating treatment choices in terms of what other people do has implications in terms of supporting autonomous and informed decision making, since it nudges patients towards conformity with what is presented as the most preferable choice on the basis of social norms.

RealTalk evidence-based communication training resources: development of conversation analysis-based materials to support training in end-of-life-related health and social care conversations

Training to enhance healthcare practitioners' capabilities in engaging people in sensitive and end-of life-related conversations is in demand. However, evaluations have either not measured, or found very limited impact on actual practice and patient experience. Training effectiveness is improved when it is based on in-depth evidence, reflects the complexity of real-life interactions, and instils principles adaptable to everyday practice. A relatively new source of in-depth evidence and practice-relevant insights on healthcare interactions is conversation analytic research, a form of observational analysis of real-life interactions. However, conversation analytic research findings have largely been disseminated by and for scientists, rather than clinicians and trainers. We used conversation analytic evidence to develop resources for use by healthcare trainers. The aim was to increase training's evidence-base and authenticity. We further aimed to develop resources applicable to working with learners ranging from novices to advanced practitioners.

METHODS

 Using an intervention development approach, we created online video-clips and supplementary written materials for professionals who deliver training, supervision, and support in healthcare communication for staff and students. The materials were reviewed by an advisory group comprising clinicians, lay consultees, educators, and researchers, and piloted by trainers in UK universities, NHS organisations and independent hospices. We refined materials based on their feedback.

RESULTS

 The resulting 'RealTalk' resources focus on practices for communicating with patients and their companions about end-of-life and prognosis. Two core training modules were developed, each comprising several patient case studies featuring video-clips from real-life healthcare consultations. The clips featured practices that patients and experienced practitioners use in approaching end-of-life matters. The case studies also included evidence-based descriptions of observable practices and the principles underlying these, alongside transcripts and case synopses.

CONCLUSIONS

 RealTalk training resources aim to facilitate evidence-based, experiential and reflective learning, focusing on communication challenges, practices and principles for end-of-life-related interactions. The resources are designed for use by trainers for delivering all levels of training, from introductory to advanced, in both formal and informal training settings. Our development process may serve as a blueprint for the production of future evidence-based training resources based on conversation analytic research.

Death and the treatment imperative: Decision-making in late-stage cancer

Care at the end-of-life in the United States has expanded in the past decade in large part due to structural changes such as increased access to hospice care, the integration of palliative care, policy mandates, and financial incentives. Despite these shifts, research shows that appropriate end-of-life care continues to be underutilized. This paper uses conversation analytic (CA) and ethnographic methods to examine doctor-patient interactions among a sample of 14 Stage IV cancer patients and the way decisions unfold about next steps in treatment during a moment that larger policy changes began to take place following passage of the Affordable Care Act. This work reveals that, despite structures designed to better facilitate end-of-life care transitions for patients in late life, doctors continue to demonstrate interactional hesitancy in discussing the possibility of a patient's end-of-life in treatment discussions and an orientation to the treatment imperative. Examining doctor-patient interaction as one key trouble source in end-of-life care implementation shows in situ evidence that the treatment imperative supersedes the structural shifts supporting less medical intervention in late life.

Using conversation analysis to appraise how novel educational videos impact patient medical education

OBJECTIVE

To determine in what ways, if any, do patients, caregivers, and nurses make videos relevant during in-person education.

METHODS

We applied conversation analysis to analyze interaction in 12 nurse-led education visits (1011 min of audio) in which speakers referred to a supplemental education video.

RESULTS

Patients initiated talk about the video in about half of the clinic visits analyzed, while nurses initiated talk about the video across all clinic visits analyzed. Interactions showed that patients demonstrated knowledge of video content and clarified information concerning their treatment plans by asking questions of nurses. Nurses referenced the video prior to repeating information that they recognized patients had viewed. In all instances analyzed, nurses made references to the videos in ways that re-oriented conversations back toward the content of the informal scripts that they used to deliver patient education.

CONCLUSION

Patients referenced the video in ways that demonstrated that they had viewed it and had gained knowledge concerning treatment plans, and to ask specific questions about these. Nurses referred to the videos by acknowledging patients' prior knowledge of upcoming information.

PRACTICE IMPLICATIONS

Understanding how pre-delivered supplemental videos impact patient involvement in in-person education contributes understanding to how video-based instruction supports patient-centered care.

Physician gaze shifts in patient-physician interactions: functions, accounts and responses

OBJECTIVES

Physician gaze towards patients is fundamental for medical consultations. Physicians' use of Electronic Health Records (EHR) affects their gaze towards patients, and may negatively influence this interaction. We aimed to study conversation patterns during gaze shifts of physicians from the patient towards the EHR.

METHODS

Outpatient consultations (N = 8) were eye-tracked. Interactions around physician gaze shifts towards the computer were transcribed.

RESULTS

We found that physician gaze shifts have different interactional functions, e.g., introducing a topic switch or entering data into the EHR. Furthermore, physicians differ in how they account for their gaze shifts, i.e., both implicitly and explicitly. Third, patients vary in treating the gaze shift as an indication to continue their turn or not.

CONCLUSIONS

Our results suggest that physician gaze shifts vary in function, in how physicians account for them, and in how they influence the conversation. Future research should take into account distinctions when relating gaze to patient outcomes.

PRACTICE IMPLICATIONS

Physicians may be aware of the interactional context of their gaze behaviour. Patients respond differently to various types of gaze shifts. How physicians handle gaze shifts can therefore have different consequences for the interaction.

Discussing care decisions at the internal medicine outpatient clinic: A conversation analysis

OBJECTIVE

Explore how often, when and how care decisions are discussed during consultations at an internal medicine outpatient clinic, and what we can learn from these observations.

METHODS

Qualitative analysis of 150 video-taped consultations. Consultations involving a discussion of care decisions were analyzed using conversation analysis.

RESULTS

1) Only 21 of the 150 consultations involved a discussion of care decisions; 2) As there is no destined phase for the introduction of the topic of care decisions, the topic is most often introduced at the end of the phase 'treatment and course of the disease'; 3) A lot of interactional effort is needed to create common ground and make relevance clear with extensive justification. Hesitation markers, repairs and hypothetical talk show the precariousness of the topic.

CONCLUSIONS

Three dilemma's need to be addressed: 1) a slot has to be created to introduce the topic of care decisions; 2) common ground has to be created, possibly over time; 3) the paradox of framing the topic as relevant 'in the future' but 'needs to be discussed now' needs to be attended to.

PRACTICE IMPLICATIONS

We recommend that physician training should address the three dilemmas. Future research should focus on how to do so.

Agency and the telephone: Patient contributions to the clinical and interactional agendas in telehealth consultations

OBJECTIVE

Patient-centredness is central to providing safe care and is achieved, in part, through involving patients in developing the agenda of the consultation. Medical consultations have changed significantly over the last two years as a result of COVID-19 and thus understanding how patients contribute to the clinical and interactional agendas within a telehealth consultation is important to supporting quality care.

METHODS

A collection (15) of consultations (in English) between specialists (3) and patients (14) were recorded in a metropolitan gastrointestinal clinic in Australia. These recordings were closely examined using conversation analysis, which focuses on the structural and sequential organisation of interaction.

RESULTS

Patients used a variety of interactional approaches to contribute to the agenda throughout the consultations. This was achieved in collaboration with the doctors, whose responses generally allowed for these contributions. However, there were few doctor-driven, explicit opportunities provided to patients to contribute to the agenda.

CONCLUSION

Many patients and doctors are adept at managing the interactional challenges of telehealth consultations but there are clear opportunities to extend this advantage to those patients with less agency.

PRACTICE IMPLICATIONS

Providing an explicit space for patients to ask questions within the consultation would support those patients less inclined or able to assert themselves during a telehealth consultation.

A direct observation of pain scale use in five video-recorded palliative care consultations: Using conversation analysis to show how practitioners support patients to describe pain

OBJECTIVE

Assessing pain intensity is an important palliative care task. Self-report pain intensity scales are frequently used within assessment. In contrast to formal studies of validity and reliability, we examine administration of, and responses to these scales in everyday palliative care.

METHODS

We searched episodes of pain scale use in a dataset of (video/audio-recorded) UK palliative care consultations involving five doctors, 37 terminally ill patients and their companions. We found five, and applied the techniques and tools of conversation analysis to characterise scales' administration and functioning.

RESULTS

Generally, the patients responded to scales by reporting multiple aspects of pain; the doctors supported and encouraged this. In two episodes, the scales generated misunderstandings. The doctors worked to resolve these in ways that avoided implying the patient was at fault.

CONCLUSION

Pain intensity scales can yield richer information than just intensity. They can also generate misunderstandings and social friction which take skill and effort to resolve.

PRACTICE IMPLICATIONS

Patients tend to respond to pain intensity scales by reporting on multiple aspects of pain, professionals should support them in this. These scales sometimes generate misunderstandings. To preserve the therapeutic relationship, professionals should work to resolve these without implying the patient is to blame.

Enhancing patient-centred communication across barriers: The case of intersubjectivity management in medical interpreting

OBJECTIVE

This study introduces the concept of intersubjectivity management in medical interpreting and identifies relevant interactional strategies employed by the interpreter, also explores their effectiveness in facilitating positive clinician-patient communication.

METHODS

We used conversation analysis (CA) to analyse 27 video recordings of interpreter-mediated dental visits, participants involve English-speaking dentists, Cantonese as the first language (L1) patients and bilingual dental surgery assistants (DSA) who also play the role of ad hoc interpreters.

RESULTS

The DSA-as-interpreter manages intersubjectivity for the dentist and patient through interactional strategies, such as reformulating action types, redesigning contents and information capacity, summarising and concentrating turns, constantly monitoring the situation and eliciting spoken or unspoken expressions that are medically relevant from both sides to validate them. The strategies effectively enabled and enhanced the mutual understanding and interpersonal alignment between the dentist and patient. More importantly, the DSA constantly orients to patient-centred communication.

CONCLUSION

Although not professionally trained for interpreting, the DSA-as-interpreters demonstrated discursive strategies. The strategies evidently facilitated positive dentist-patient communication and relationships.

PRACTICE IMPLICATIONS

The conceptualisation and significant strategies demonstrated by the DSA-as-interpreters could potentially inform the solution of enhancing multilingual health communication in clinical staff training.

Particularizing the picture: Features and uses of instantiation stories told by clinicians doing autism diagnosis

Diagnosis is the narrative process through which professional clinicians transform experiences of illness and disability into disease (Hunter, 1991; Jutel, 2009; Kleinman et al., 1978). Maynard and Turowetz (2017a) found that the narrative structure for autism diagnosis consists of two primary story types concerning the conduct of children under assessment: (1) tendency stories about propensities or quantifications of behavior, and (2) instantiation stories that describe single instances of conduct occurring at a specific time or place. Instantiation stories represent a mechanism by which clinicians might preserve particulars about children under assessment in a way that is informative for configuring diagnoses that attend to the child's individuality rather than as a generic autistic child. This paper constitutes an investigation into the uses and features of instantiation stories as told by clinicians doing autism diagnosis. Clinicians primarily use instantiation stories to support generalizations about the child that relate to official diagnostic criteria (Excerpt 1). Clinicians also use instantiation stories to index instances of conduct that apparently misalign with a tendency description and the diagnostic picture (Excerpt 2). In such cases, clinicians work to demonstrate how the generalization endures despite the apparent misalignment. Furthermore, clinicians may use instantiation stories to tell about humorous or otherwise "storyable" (Sacks, 1992) conduct (Excerpt 3). Finally, clinicians sometimes use instantiation stories to mitigate the delivery of a diagnosis (Excerpt 4).

Pretense Awareness Context and Autism: Insights from Conversation Analysis

Utilizing approaches from Conversation Analysis and Interactional Sociolinguistics, this study investigates linguistic resources related to discourse while playing a tabletop roleplaying game, with particular investigation around the discourse of individuals with autism spectrum disorder. The study examines interactions as they take place across three frames that are associated with interaction in this community of practice: the primary frame, the metagaming frame, and the character frame. The study found that the participants with autism frequently violated the stable pretense awareness context that persists across these frames in tabletop roleplaying game discourse. This research has implications for social skills training methods and psychological models of autism symptomatology.

"Do you want us to try to resuscitate?": Conversational practices generating patient decisions regarding cardiopulmonary resuscitation

OBJECTIVE

To explore how physicians elicit patients' preferences about cardio-pulmonary resuscitation (CPR) during hospital admission interviews.

METHODS

Conversation analysis of 37 audio-recorded CPR patient-physician discussions at admission to a geriatric hospital.

RESULTS

The most encountered practice is when physicians submit an option to the patient's validation ("do you want us to resuscitate"). Through it, physicians display presuppositions about the patient's preference, which is not elicited as an autonomous contribution. Through open elicitors ("what would you wish"), physicians treat patients as knowledgeable about options and autonomous in determining their preference. A third practice is related to patients delivering their preference in anticipation of the request and is encountered only for choices against CPR. These decisions are revealed as informed and autonomous, and the patient as collaborative.

CONCLUSION

The way that physicians elicit patients' preferences about CPR influences the delivery of autonomous and informed decisions. Our findings point to an asymmetry in ways of initiating talk about the possibility of not attempting CPR, potentially exacerbated by the context of admission interviews.

PRACTICE IMPLICATIONS

Decisions about the relevancy life-sustaining interventions need an adequate setting in order to allow for patient participation. Our findings have implications for communication training in regard to involving patients in conversations about goals of care.

Negotiating 'the problem' in GP home visits to people with dementia

People with dementia are often marginalised in health care due to the effects of the condition on short term memory and communication. The problem presentation is a key area of primary care consultations where patients 'have the floor', and hence are able to direct the trajectory of the consultation to achieve certain ends. An exploration of how patients with advanced dementia participate in this stage of the consultation can thus demonstrate their participation and subsequent engagement. We used conversation analysis to describe how healthcare professionals (HCPs), people with dementia, and their carers establish the presenting problem in 17 out-of-hours primary care home visit consultations. In all cases, the carer had called the out of hours service on behalf of the patient. Rather than traditional "what can I help you with?" problem solicits, HCPs instead stated their reason-for-visit using information provided by the carer. All the patients showed some misalignment with this presented reason-for-visit, by denying the existence of current symptoms and/or their involvement in the decision to call the doctor. Carers appeared to show respect for the patient's ownership of their experience, only providing input on invitation from doctors or patients. Patient acknowledgement and willingness to engage in examination were needed for progressivity, but agreement with the reason-for-visit was not. In two consultations, the reason-for-visit was not explained to patients, and in both cases this resulted in the person with dementia showing frustration and resistance to examination. People with dementia may resist doctor home visits for many reasons, such as embarrassment for not remembering symptoms, or stoicism in the face of medical ailments. These findings show how the balance of progressivity and intersubjectivity tips towards progressivity in consultations with people with dementia, but this is reversed when the patient is not engaged in the reason-for-visit.

Interaction order and disorder: How parents mobilize personal knowledge to resist medicalization of their children's behavior

This paper examines how parents of children diagnosed with autism resist the medicalization of their children's behavior. Drawing on video and ethnographic data collected over four years of fieldwork at a clinic for developmental disorders, the paper distinguishes two orders of practice - that of the clinic and that of the family - and argues that behavior which is interpreted as disordered in the clinic may be seen as ordinary in the home. These different interpretations reflect and renew distinct orders of sensemaking in the clinic and home, and parents mobilize familial knowledge of the child to counter the medicalization of specific behavior patterns, even where they otherwise accept an autism diagnosis. In showing how medicalization and labelling are achieved and resisted in the mundane details of social interaction, the paper contributes to studies of diagnosis, disability, and deviance. Further, the myriad ways parents and clinicians contest which regions of a child's behavior get medicalized - i.e. which behavioral patterns are labeled disordered - present a challenge to binary conceptions of medicalization, recommending instead a more nuanced model of medicalization as a multi-dimensional continuum: more or less, rather than either-or.

[Incredible language! A qualitative investigation of conversations about delusions]

BACKGROUND

Communicating about delusions is generally considered a challenging task.

MATERIAL AND METHODS

Assuming that there are nevertheless a variety of communicative resources competently employed to meet this challenge, the authors present a conversation analytic study of two narrative interviews in which people talk about their experience of delusions.

RESULTS

It is shown that through pauses, breaks, reformulations, negotiations of the so-called common ground and the use of metaphoric speech, they succeed in conveying many aspects of the experience of delusions that cannot simply be described in terms of content.

CONCLUSIONS

These examples of communicative strategies can be a resource for others and encourage mental health professionals and users alike to engage in conversations on delusions.

To like or not to like: Negotiating food assessments of children from families with a low socioeconomic position

The present study explored how primary school-aged children from families with a low socioeconomic position produce 'likes' and 'dislikes' of foods during everyday family meals, and how these (dis)likes are understood and treated by their parents. It is crucial to understand how food preferences develop in the course of everyday life, as it is known that there are socioeconomic disparities in food preference and consumption, and that children from families with a low socioeconomic position have relatively poorer diets. Deploying an interactional approach to food preference, video recordings of 79 evening meals in families with a low socioeconomic position were analyzed using discursive psychology and conversation analysis. The analysis highlighted that children's food likes and dislikes were treated differently by their parents. While likes were routinely not responded to, agreed with or further elaborated, dislikes were predominantly oriented to as food refusals or treated as inappropriate, or non-genuine claims. Children's food assessments, i.e., likes and dislikes, were often disattended by parents when they appeared to be food preference displays. By contrast, assessments that accomplished social actions like refusals and complaints were more often responded to. The analysis also revealed the importance of distinguishing between assessments about food items in general, that were not currently being eaten, and assessments of food eaten here-and-now. All in all, the study evidences that and how assessment sequences open up interactional spaces where children and parents orient to and negotiate relative rights and responsibilities to know, to assess and to accomplish specific actions. Implications for food preference research are discussed.

Communicating with patients and families about illness progression and end of life: a review of studies using direct observation of clinical practice

BACKGROUND

There is growing recognition that a diverse range of healthcare professionals need competence in palliative approaches to care. Effective communication is a core component of such practice. This article informs evidence-based communication about illness progression and end of life through a rapid review of studies that directly observe how experienced clinicians manage such discussions.

METHODS

The current rapid review updates findings of a 2014 systematic review, focussing more specifically on evidence related to illness progression and end-of-life conversations. Literature searches were conducted in nine bibliographic databases. Studies using conversation analysis or discourse analysis to examine recordings of actual conversations about illness progression or end of life were eligible for inclusion in the review. An aggregative approach was used to synthesise the findings of included studies.

RESULTS

Following screening, 26 sources were deemed to meet eligibility criteria. Synthesis of study findings identified the structure and functioning of ten communication practices used in discussions about illness progression and end-of-life.

CONCLUSION

The ten practices identified underpin five evidence-based recommendations for communicating with patients or family members about illness progression and end of life.

When do patients exercise their right to refuse treatment? A conversation analytic study of decision-making trajectories in UK neurology outpatient consultations

Using conversation analysis, this paper investigates when patients exercise their right to refuse treatment in neurology outpatient consultations recorded in the UK's National Health Service in 2012 (n = 224). NHS patients have a right to refuse treatment. However, there are good reasons to suppose that this may be difficult to exercise in practice. We know that clinicians tend to pursue acceptance if it's not forthcoming and those studies that have tracked decision-making trajectories through to their outcomes have shown that clinicians typically convert resistance to acceptance. By contrast, I show that, in 35/40 (87.5 %) cases in which patients sought to refuse treatments made available by a neurologist, they left without a prescription or referral. This paper seeks to explain this apparently anomalous finding. Starting with an example of what I expected to find - a 'duel' that ends with the neurologist persuading the patient to accept treatment - I show that this is, in fact, the exception. By contrast, most of the (attempted) refusals are collaborative, occurring after the neurologist has initiated decision-making in a way that designedly foregrounds the patients' views as the basis for deciding. I show also that, having done so, the neurologists typically continue to treat the decision as subject to the patient's preferences. Thus, the trajectories in my collection - despite including attempts to refuse treatment - do not typically become duels. Rather, patients are refusing treatment in a sequential context that facilitates making their own decision.

Downgrading Deontic Authority in Open Dialogue Reflection Proposals: A Conversation Analysis

The Open Dialogue approach promotes collaboration with clients and families in decisions about the direction of therapy. This creates potential problems for Open Dialogue therapists who seek collaboration but also have responsibility for managing the session. Using conversation analysis, we examined 14 hours of video recordings of Open Dialogue sessions, and specifically how therapists proposed the transition to a reflecting conversation. We found that, when making proposals to reflect, therapists routinely downgrade their deontic authority (i.e., adopt a less powerful, more collaborative position). They did this through framing proposals as interrogatives, providing accounts, and by prefacing their proposals with "I'm wondering". More heavily downgraded proposals made acceptance less salient, potentially risking transition to the reflection. These findings provide more detail on how theoretical concepts such as "collaboration" and "power" are actually displayed and negotiated in practice and can contribute to a more nuanced understanding of what constitutes Open Dialogue.

Dietary advice in chronic care: Comparing traditional Chinese and western medicine practiced in mainland China

The study examines dietary advice-giving in regular consultations for patients with chronic conditions in two types of clinical practices: Traditional Chinese Medicine and Western Medicine practiced in mainland China. Dietary habits are unanimously considered relevant to the patient's health, particularly in chronic conditions. This article reports the differences in where and how dietary advice is occasioned and co-constructed by participants in two settings. One significant finding of this paper is that while Traditional Chinese Medicine doctors take dietary talk to instruct patients and put it into the treatment recommendation, WM doctors may treat it as incidental and only valuable for diagnostic assessment, leaving its treatment opaque and not discussed with the patient. Data are in Mandarin Chinese. Using Conversation Analysis, the article describes the interactional organisation of dietary advice delivery in different medical practices and ascribes their differences to clinical pathology.

A pilot of modified Conversation Analytic Role-play Method for one-to-one clinical communication training

OBJECTIVE

It can be difficult to identify specific skills to improve communication, particularly if feedback is generalised or vague. With the aim of providing specific feedback for improved doctor-patient communication, we piloted a modified Conversation Analytic Roleplay Method (CARM) for one-to-one training.

METHODS

We recorded one surgical registrar during ward rounds in a hospital. These seven consultations were then analysed and an individualised CARM workshop, utilising the findings and related published evidence, was developed and delivered. One month after this workshop, another nine consultations were recorded and analysed.

RESULTS

There were three "trainables" identified in the initial analysis that formed the basis of the personalised workshop. Analysis of the post-training recordings showed that the verbal behaviours were mostly modified but the non-verbal behaviour generally was not.

CONCLUSION

By facilitating reflection on and close analysis of his own interaction using CARM, we were able to assist this doctor in modifying some of his communication behaviours.

PRACTICE IMPLICATIONS

Personalised video-based training enables the identification of an individual's practice, allowing for specific feedback and engaging participants with the analysis of their own talk. This makes it potentially an ideal method for helping those struggling to improve with other training methods.

Lifestyle advice in UK Primary Care consultations: Doctors' use of conditional forms of advice

OBJECTIVE

To investigate how doctors deliver lifestyle advice to patients in ordinary general practice consultations.

METHOD

A secondary analysis of audio/video recorded primary care consultations between doctors and patients. Instances of lifestyle related talk were identified and analysed according to the methods of Conversation Analysis.

RESULTS

The most frequently used format for delivering advice was found to be if-conditional forms. Conditional forms work to convey how advice is relevant to the individual's health circumstances 1) topicalising the problematic risk to the patient, 2) informing and warning the patient of reoccurring or future health risks, and 3) offering changes in lifestyle in addition to or as a replacement for medication.

CONCLUSION

The results show that doctors use if-conditional constructions to navigate anticipated or actual difficulties evidenced through misalignment in delivering lifestyle advice, by conveying the importance of the advice to the individual patient.

PRACTICE IMPLICATIONS

Using if-conditional constructions when talking with patients regarding their problematic risk factors provides a technique enabling doctors to navigate the sensitivities associated with giving advice, whilst delivering personalised and preventative medicine.

Discussing mental health difficulties in a "diagnosis free zone"

Being identified as "mentally ill" is a complicated social process that may be stigmatizing and socially problematic, as a mental illness diagnosis determines the criteria for what is considered normal. This has given rise to a number of anti-stigma campaigns designed to create awareness of the way stigmas affect people with mental health difficulties and to normalize those difficulties in society. One such campaign is the "diagnosis-free zone", which declares that those with mental health difficulties should not be categorized on the basis of their diagnosis; rather, they should be encountered as full individuals. In this paper, we investigate how mental health difficulties are discussed in Clubhouse communities, which adhere to the "diagnosis free zone" programme. The findings are based on conversation analysis of 29 video-recorded rehabilitation group meetings, in one Finnish Clubhouse, intended to advance clients' return to the labour market. The analysis demonstrated that members referred to their mental health difficulties to explain the misfortunes in their lives, especially interruptions and stoppages in their careers. By contrast, staff members disattended members' explanations and normalized their situations as typical of all humans and thus unrelated to their mental health difficulties as such. In this way, the discussion of mental health difficulties at the Clubhouse meetings was implicitly discouraged. We propose that the standards of normality expected of a person not suffering from a mental health difficulty may well be different from the expectations levelled at participants with a history of mental problems. Therefore, instead of considering cultural expectations of normality to be a unified domain, effective anti-stigma work might sometimes benefit from referring to mental-health diagnoses as a means of explicitly tailoring expectations of normality.

Communicating with older adults with long-term conditions about self-management goals: A systematic review and thematic synthesis

OBJECTIVE

To synthesise a body of fine-grained observational research on communication between healthcare professionals (HCPs), older adults, and carers regarding self-management goals and actions.

METHODS

We conducted a systematic review, searching nine electronic databases and the grey literature. Two reviewers independently selected for inclusion following a two-stage process and studies and discrepancies were resolved through consultation with the review team.

RESULTS

898 records were retrieved, and eight studies were included in the review. Aggregative thematic analysis resulted in 13 categories of communication practices across three decision-making domains: (1) initiating: actions occurring prior to the commitment point; (2) proposing: putting forward a course of action; and (3) committing and closing: committing (or not) to the course of action.

CONCLUSIONS

Despite an increasing emphasis on the importance of personalised care planning and shared decision-making (SDM) to support older people's health and wellbeing, HCPs did not consistently practice this approach and, in some cases, worked in opposition to it.

PRACTICE IMPLICATIONS

We encourage HCPs to prepare older adults to engage actively with SDM and the goal setting process by employing patient-centred communication resources. These could assist with identifying different types of goals that are realistic and relevant to patients in daily life.

Women's (limited) agency over their sexual bodies: Contesting contraceptive recommendations in Brazil

Unintended pregnancies constitute a serious public health concern in Brazil, representing up to 55% of all pregnancies, and are prevalent among women with low income and low educational backgrounds. Lack of assistance to women in their decision-making has hindered the adoption of more effective contraceptive models. Although clinical consultations constitute an important locus to assist women in decision-making and to facilitate access to subsidized methods, our current knowledge of how contraception is discussed and decisions are reached in actual consultations is limited. Just as scarce is our knowledge of how patients respond and resist contraception recommendations and how physicians counter or accommodate patients. Using a corpus of 103 audio-recorded medical visits and conversation analytic (CA) methods, this paper examines recommendation sequences in the under-investigated gynecological consultations in the Brazilian public healthcare system (SUS). The quantitative analysis reveals a strong orientation to physicians as having primary rights to govern the oversight of women's bodies: 94% of the recommendations are delivered as pronouncements (e.g., "You'll take X″), the most authoritative action type. Patients largely assume an agreeable and passive role (66%), leading to scarce negotiation and minimal involvement in decision-making. However, in a few cases (12%), all involving contraception, patients become overtly agentive, responding with active resistance. A qualitative analysis of that subset shows that despite women's gaining some agency over their sexual bodies, that agency is still limited. Whereas physicians accommodate patient resistance on grounds of biomedically-related side-effects and incorrect assumptions about the women's lives, they overlook patient resistance based on gendered struggles over contraceptive methods in the domestic sphere. By failing to consider women's lack of agency in choosing whether to have sex or to use condoms, doctors show unawareness of significant consequences of the recommended method, which might include domestic dispute and violence and, paradoxically, ultimately misfire, leading to unwanted pregnancy.