Digital technology in medical visits: a critical review of its impact on doctor-patient communication.

With the rapid advances of digital technology, computer-mediated medical practices are becoming increasingly dominant in medical visits. However, the question of how to ensure effective, patient-centered communication in this transition remains crucial. In this mini-review, we explore this topic by reviewing quantitative and survey-based studies, as well as discursive-interactional studies that focus on the visit as a communicative event. The review is organized into four sections: the introductory section provides a brief synthesis of the two main models used in medical practice and describes the effects of patient-centered communication practices on patients' health and well-being. The second section presents and discusses qualitative and quantitative studies that assess the effect of technology on medical interaction and its impact on patient-centered communication. The third section focuses on whether and how the digital medical record represents a "potential communication risk" during doctor-patient interactions and explores how certain pen-and-paper literacy practices could help mitigate these challenges. In the concluding section, we outline and analyze three key considerations for utilizing technologies to foster and enhance patient-centered communication during medical visits.

Navigating Intercultural Medical Encounters: An Examination of Patient-Centered Communication Practices with Italian and Foreign Cancer Patients Living in Italy.

Effective communication is crucial in cancer care due to the sensitive nature of the information and the psychosocial impact on patients and their families. Patient-centered communication (PCC) is the gold standard for providing quality cancer care, as it improves patient satisfaction, treatment adherence, clinical outcomes, and overall quality of life. However, doctor-patient communication can be complicated by ethnic, linguistic, and cultural differences. This study employed the ONCode coding system to investigate PCC practices in oncological visits (doctor's communicative behavior, patient's initiatives, misalignments, interruptions, accountability, and expressions of trust in participants' talk, Markers of uncertainty in doctor's talk, markers of emotions in doctor's talk). Forty-two video-recorded patient-oncologist encounters (with 22 Italian and 20 foreign patients), including both first and follow-up visits, were analyzed. Three discriminant analyses were conducted to assess differences in PCC between patient groups (Italian or foreign patients) according to the type of encounter (first visit or follow-up) and the presence or absence of companions during the encounters. Multiple regression analyses were performed to evaluate the PCC differences by oncologist age, patient age, and patient sex, controlling for the type of encounter, the presence of a companion during the visit, and patient group on ONCode dimensions. No differences were found in PCC by patient group in discriminant analyses and regressions. Doctor communication behavior, interruptions, accountability, and expressions of trust were higher in first visits than in follow-ups. The disparities in PCC were primarily linked to the type of visit and the age of the oncologist. However, a qualitative analysis showed notable differences in the types of interruptions during visits with foreign patients compared to Italian patients. It is essential to minimize interruptions during intercultural encounters to foster a more respectful and conducive environment for patients. Furthermore, even when foreign patients demonstrate sufficient linguistic competence, healthcare providers should not solely rely on this factor to ensure effective communication and quality care.

Group Membership and Social Identities in a Formative Intervention in a Mexican Hospital.

Formative intervention is a participatory methodology that supports organizational change by means of an interactive and systematic dialogue carried out by researchers and participants. In this process, the researchers contribute to expanding the conversational space in the organization by supporting participants in examining and reflecting on their own work practices, as well as in modeling, shaping, and experimenting with innovations. Drawing on transcripts of videotaped sessions, this study analyzes how change is discursively sustained by the researchers who conduct the meetings within a formative intervention in a Mexican hospital. The quantitative and qualitative analysis focuses on the collective pronoun "we" as a membership categorization device deployed by the researchers for rhetorical and pragmatical aims, such as questioning about the state of necessity for the intervention, engaging the participants, or introducing a proposal of innovation with the participants. Results show how group membership and social identity markers are used by researchers to support emerging forms of collaboration, involvement of participants and the creation of common ground during the intervention process. In terms of the practical implications of the study, an informed and strategic use of membership categorization devices used by the researcher can increase the effectiveness of their formative and expansive role.

"Awareness to touch": A qualitative study of nurses' perceptions of interpersonal professional contact after an experiential training.

AIM: This study aimed to explore nurses' perceptions of touch in their professional practice and how these perceptions were articulated in discourse, among participants who attended a specific training on touch and those who did not. BACKGROUND: Touch is an essential part of nursing practice. Research showed that the use of touch influences patients' general well-being, improving a sense of presence and infusing security and encouragement. Nurses' attitude towards touch influence positively their job satisfaction and reduces burnout syndrome risks. Nevertheless, there are very few studies describing specifically nurses' perceptions and opinions about the use of interpersonal physical contact in the clinical setting. Also, an educational perspective focusing on touch seems missing from nursing curricula and research. DESIGN: A qualitative methodology was adopted. Focus groups were organized to explore how nurses define and interpret touch and its relevance in their professional practice. The findings obtained in a previous quantitative step of this research inspired the formulation of the questions posed to nurse participants. METHODS: Six focus groups were conducted in three Italian hospitals, which also hosted a one-day training on touch. For each hospital, a purposive sampling approach was used to organize two focus groups: one was made up of nurses who attended the training, and one was made up of nurses who did not. Qualitative thematic analysis was used to identify recurring patterns of meaning by which touch is discussed and interpreted in the focus groups. RESULTS: Registered nurses (N = 39) from different clinical experiences participated in six focus groups. The analysis identified four themes: 1) Touch preferences, 2) Touch and Contact as a natural dimension, 3) Touch as a "praxis" and 4) Reflexivity on Touch. All six focus groups showed a general awareness of interpersonal touch and discussed it as a highly valorized (personal and professional) dimension. Specifically, the trained nurses showed a greater variety and richness of their lexicon, a semantic and imaginary repository by which they described their experience and competence. CONCLUSIONS: This study highlights that nurses consider touch as an important, essential part of their practice. Moreover, it suggests that specific training on interpersonal touch in nursing care facilitate nurses to shift their perceptions from a generic, abstract and "personal" dimension, into an articulated, disciplined and specialized practice. This has implications for education on touch in nursing.

Being in Place: A Multimodal Analysis of the Contribution of the Patient's Companion to "First Time" Oncological Visits.

Companions to medical visits have been alternatively viewed as members who "support" or "inhibit" and "interfere" with the doctor-patient interaction. One way of looking at the companions' contribution to medical visits is by coding roles or functions of their communicative behavior. Our paper aims at reconsidering these findings and analyzing how the companion participation is a local and sequential accomplishment, changing from time to time in the consultation. The paper relies upon an overall collection of 58 videorecordings of first oncological visits. Visits were conducted in two different hospitals, one of which a University hospital, and by different oncologists, including both senior professionals and (in the second setting) medical students in oncology. Visits were fully transcribed according to the Jeffersonian conventions and authors examined the transcripts and video according to the methodology of Conversation Analysis. The aim of the paper focused on how patient's companions orient and contribute to the accomplishment of the different aims and activities at different stages of the visit as an institutional speech event. The multimodal analysis of turns and actions (such as, gaze shifts, prosodic modulation, bodily arrangements), and the close examination of the sequential and temporal arrangements of companions' and their co-participants' turns revealed that companions finely attune to the multiparty framework of the encounter and the institutional constraints that govern the oncological first visit. Overall, results show two relevant features: that companions act as to preserve the doctor-patient interaction and to maintain the patient as the most responsible and legitimate agent in the interaction; that companions' contributions are relevant to the activities that sequentially unfold at different stages in the consultation (e.g., history taking, problem presentation, treatment recommendation etc.). The study complements earlier findings on the companion's roles, showing how these are highly mobile, multimodal and multiparty accomplishments, and they are tied to the specific contingencies of the visit. The results solicit to consider the value of multimodal analysis in understanding the complexity of multiparty communication in medical setting, and make it usable also in medical education.

Social support for breast cancer patients in the occupied Palestinian territory.

Previous research indicates that social support is beneficial to cancer patients in adjusting to the stress of the disease. Drawing on a qualitative content analysis of 36 semi-structured interviews, this article explores sources and types of social support in Arab-Palestinian women with breast cancer. Results show that members of the immediate family, husbands in particular, are reported to be the most supportive social sources. Given the limitations that characterize access to cancer care in the occupied Palestinian territory (OPT) and the collectivistic values of the society, women with breast cancer seem to rely mainly on their husbands to handle emotional, functional and informational needs. Emotional support includes the provision of care, trust, reassurance, and companionship. Functional support includes the practical assistance that the cancer patients receive in terms of financial support, attendance during treatment or help with domestic chores and childcare. Accessing appropriate informational support can be quite challenging in the OPT since available information is not always reliable. The family plays a key role in mediating communication with doctors. Contact with breast cancer patients and survivors is also a source of supporting information, with however a possible negative impact in terms of emotional coping. In this context, the immediate family becomes a fundamental resource for coping and a relational space that mediates connections with others, including doctors, acting as a "proxy" between the patient and the social environment. Findings are discussed in light of the historical and sociocultural context of the OPT.

Becoming a Psychotherapist: Learning Practices and Identity Construction Across Communities of Practice.

Within a perspective that views groups as communities of practice and sites of construction of knowledge, learning, and identity, this article aims to explore the contribution that participation in different groups over the course of one's life provides to the development of the professional practices of psychotherapist trainees enrolled in the C.O.I.R.A.G. school, an Italian graduate program in group psychotherapy. Through qualitative analyses of 10 semi-structured interviews, our study empirically shows that by participating in groups, the trainees not only learn the practices of that group but also develop a sort of meta-learning which takes place across groups. The results highlight that: (1) Transversality, duration, and informality are found to be the group properties with the highest formative value; and (2) Learning practices across different groups have common characteristics: are organized around complex topics of group life (e.g., how to manage conflicts, how to join and leave groups, etc.), began in early group experiences, are in continuous evolution, are associated with a critical event, and a negative affect. At the same time, it seems that these critical events are exactly what triggered and sustained the learning practices. Data from the interviews also showed how professional identities are constructed as the outcome of learning in different communities of practice. The study outlines how the experience made in different groups is elaborated in and through meaningful self-narratives, highlighting them as a fundamentally collective and culturally shaped sense-making process. Overall, these results contribute to a better understanding of learning processes as situated and jointly constructed through multiple group participations over time. Furthermore, they contribute to highlighting the role of self-narratives as a primary way through which trainees shape their identity as self-reflexive professionals who are competent in reading group dynamics. Directions for future research and suggestions for psychotherapist training paths are outlined in the conclusions.

A room of one's own: Moments of mutual disengagement between doctor and patient in the oncology visit.

OBJECTIVE: This paper examines a previously neglected phenomenon in doctor-patient interaction studies, i.e. the achievement of mutual disengagement-a specific state of coordination, in which participants suspend reciprocal gaze and turn into separate axes of involvement. In the specialized setting of the oncology visit, which we consider in this study, mutual disengagement is linked to important tasks that the oncologist has to carry out, notably the scrutiny of the histological exam during the diagnostic assessment phase. METHODS: Our data corpus includes 56 video-recorded oncology visits. We employ conversation analysis to discern how mutual disengagement is achieved, sustained and ended. RESULTS: Our analysis shows that suspension of mutual engagement is a joint accomplishment that requires intersubjective cooperation. It also reveals that when talk and reciprocal engagement are suspended, intersubjective alignment is more vulnerable to breakdown. CONCLUSION: Our findings eschew a characterization of the oncologist as solo arbiter of the interactional exchange. An alignment with the patient is key to the felicitous accomplishment of the visit. We also suggest that a successful medical encounter is not only characterized by harmonious verbal communication, between doctor and patient, but also by felicitous pauses in their joint engagement. PRACTICE IMPLICATIONS: In building a room of one's own, the oncologist has the responsibility to co-construct with the patient an experience of interactional attunement and mutual understanding.

Presenting treatment options in breast cancer consultations: Advice and consent in Italian medical care.

Variety, complexity and uncertainty in the therapy outcomes of cancer illness make the treatment recommendation (TR) in oncology a "monumentally difficult task". Previous studies have distinguished unilateral and bilateral formats of treatment recommendations, accordingly to whether, or to what extent, the patient's perspective is included in the consideration of therapeutic options. Others have also shown how the oncologists' presentation of therapeutic options varied accordingly to the severity of the diagnosis and the availability of alternatives. Yet, no study has systemically dentified and compared components of treatment recommendation in oncology on a common set of patients and clinicians. This paper analyzes how different options in breast cancer treatments - radiotherapy, hormone therapy and chemotherapy - are presented and discussed in a set of 12 first post-surgical breast cancer visits carried out by two oncologists of high experience and seniority in two Italian hospitals. Treatment recommendation sequences involving these three option types were analyzed using the methods of conversation analysis. They were also coded for the mention of side effects and treatment burden, and for whether consent to the recommendation was invited, or expressed by the patient. Results show that radiotherapy is presented as presupposed as an extension of surgery and is not further discussed, and hormone therapy is delivered as good news and as not implying any health or lifestyle burdens. Treatment burdens were raised in the much more extensive discussions of chemotherapy, which were also accompanied by a higher chance that the patient was asked for consent to therapy. Implications are drawn as regards the extent to which clinical practice meets theory in communication protocols available in oncology, and how to consider the doctor-patient partnership and the concept of shared decision-making in such an encounter.

Structuring times and activities in the oncology visit.

In this paper we examine how doctor and patient coordinate actions in interaction towards the smooth accomplishment of the medical visit. Such coordination entails primarily the management of time and praxis, i.e. the apportionment of time to the tasks to be completed during the visit; and it is not an easy enterprise, for a number of reasons: 1) the tasks to be carried out during the visit are not familiar in equal measure to doctor and patient; 2) the extent of attention to be devoted to each task cannot be fully determined in advance but requires ongoing judgment and calibration; 3) generally, the timeframe of the visit is relatively limited. Our ethnographic and conversation analytic study of oncological visits shows that doctor and patient rely on a range of semiotic resources to achieve mutual understanding and coordinated actions. In particular, our analysis has identified textual artifacts and metapragmatic utterances as key semiotic components in the coordination and negotiation of the temporal trajectories and courses of actions that constitute and traverse the oncology visit.

Managing risk and patient involvement in choosing treatment for cancer: an analysis of two communication practices.

Drawing on conversation analyses of oncology consultations collected in Italy, the article examines the communication practices used to recommend treatments. We found that the oncologist formulates the treatment recommendation (TR) for high-risk patients in terms of a 'mandatory' choice and for low-risk patients as an 'optional' type of decision. In the first case the doctor presses to reach a decision during the visit while in the second case leaves the decision open-ended. Results show that high-risk patients have less time to decide, are pressured towards choosing an option, but have more opportunities for involvement in TR during the visit. Low-risk patients instead have more time and autonomy to make a choice, but they are also less involved in the decision-making in the visit time. Moreover, we document that TR is organised through sequential activities in which the oncologist informs the patient of alternative therapeutic options while at the same time building a case for the kind of treatment she/he believes to be best for the patient's health. We suggest that in this field risk plays a key role in decision-making which should be better understood with further studies and taken into account in the debate on shared decision-making and patient-centred communication.

Communicating Uncertain News in Cancer Consultations.

In cancer communication, most of the literature is in the realm of delivering bad news while much less attention has been given to the communication of uncertain news around the diagnosis and the possible outcomes of the illness. Drawing on video-recorded cancer consultations collected in two Italian hospitals, this article analyzes three communication practices used by oncologists to interactionally manage the uncertainty during the visit: alternating between uncertain bad news and certain good news, anticipating scenarios, and guessing test results. Both diagnostic and personal uncertainties are not hidden to the patient, yet they are reduced through these practices. Such communication practices are present in 32 % of the visits in the data set, indicating that the interactional management of uncertainty is a relevant phenomenon in oncological encounters. Further studies are needed to improve both its understanding and its teaching.

Formulating treatment recommendation as a logical consequence of the diagnosis in post-surgical oncological visits.

OBJECTIVE: the article analyzes how a doctor delivers diagnoses and recommends treatment in a set of post-surgical oncological visits. The pattern of activities are explored in two different cases: when all diagnostic information is available, and when information is still missing. METHODS: The data consist of 12 video-recorded visits of breast cancer patients to a senior oncologist. Conversation analysis is employed to analyze sequences in which the delivery of diagnosis and treatment recommendation unfold. RESULTS: The oncologist formulates the treatment recommendation as a logical consequence deriving from the available diagnostic information. In cases when definitive diagnostic information on the cancer type is missing, the oncologist opts to anticipate hypothetical diagnostic scenarios, and to draw the therapeutic alternatives as logical outcomes envisionable from each of the different scenarios. CONCLUSION: The communicative practice appears functional to encourage the patients' acceptance of a single treatment option rather than present the patients to and involve them in deliberating over multiple available treatment alternatives. PRACTICE IMPLICATIONS: Rather than a normative adoption of existing protocols of communication in cancer care, a better understanding of communication practices in use can help practitioners to reflect upon and make intentional choices about different arrangements for the patient's participation.