How physicians describe outcomes to HCV therapy: prevalence and meaning of "cure" during provider-patient in-office discussions of HCV.

BACKGROUND: How physicians convey information about hepatitis C virus (HCV) impacts patients' perceptions of treatment outcomes and informed therapy decisions. However, HCV patients reported difficulties communicating with their physicians in a recent study. Another study showed that 45% of patients did not understand projected response rates conveyed by providers, and patients with unfavorable projected treatment outcomes were more likely to lack understanding. GOALS: This article analyzes naturally occurring patient-provider interactions to evaluate physicians' use of the word 'cure', and framing of HCV response as optimistic, pessimistic, or neutral, to suggest possible reasons why patients with unfavorable projected sustained virologic response rates might perceive their odds as more favorable than they are. STUDY: Gastroenterologists, allied health professionals, and HCV patients were video and audio-recorded during regular scheduled visits. Recordings were transcribed and analyzed using validated sociolinguistic techniques. RESULTS: Sixty-three percent of physicians used the word 'cure' in 38% of visits involving response discussions. 'Cure' most frequently meant 'absolute cure' and occurred more commonly in visits conducted before therapy initiation, and with patients having favorable genotypes. Physicians hedged the meaning of 'cure' in 29% of visits. Moreover, 69.5% of response-related utterances were framed optimistically. CONCLUSIONS: HCV dialogs are characterized by the prevalence of 'cure' and optimistic framing. These positive language attributes could potentially contribute to the misunderstanding regarding the projected response rates. During treatment outcome discussions, the physicians should attempt to (1) operate using the same definition of the therapy outcome as the patient, (2) balance medically accurate information with patient comprehension, and (3) consider possible consequences of discussing treatment options on the basis of message framing.

Improving in-office discussion of chronic obstructive pulmonary disease: results and recommendations from an in-office linguistic study in chronic obstructive pulmonary disease.

Effective management of chronic obstructive pulmonary disease (COPD) requires successful physician-patient communication. Unfortunately, however, both parties often report problematic communication. Accommodating patients' desire for more information and an increased role in decision-making can increase their satisfaction surrounding the dialogue. This study analyzed naturally occurring interactions to assess in-office COPD discussions, identifying best practices and gaps in communication. In-office discussions of a study population of 17 community-based physicians and 32 outpatients with COPD (59% women; mean age, 69.5 years) were recorded during regularly scheduled visits. Individual postvisit interviews were conducted to clarify health history and perceptions of the office visit. Recordings were transcribed and analyzed using validated sociolinguistic techniques. Physicians initiated discussions of COPD with the term "breathing" in 56% of visits; these discussions focused on the acute nature of the disease, including an average of 6.4 physician-initiated, symptom-related questions. In postvisit interviews, participants (patients versus physicians) were frequently misaligned about the severity of, as well as the patient's level of concern about, the disease. Quality-of-life discussions were largely absent from visits, although patients offered emotionally charged responses postvisit about the impact of COPD in their lives. Despite accepted guidelines, discussions on smoking cessation, spirometry, and inhaler technique were underused. To reduce observed gaps in communication, physicians can focus on 4 topic areas: (1) communicating COPD diagnosis and test results, (2) optimizing disease education, (3) prioritizing smoking cessation, and (4) demonstrating correct inhaler use. Simple communication techniques, including consistent vocabulary, perspective display series, the 5 As of smoking cessation (ask about tobacco use, advise to quit, assess willingness to make a quit attempt, assist in quit attempt, arrange follow-up), and inhaler training, can maximize in-office efficiency. Combining these topic areas and communication techniques could result in higher levels of physician and patient satisfaction.

Physicians, nonphysician healthcare providers, and patients communicating in hepatitis C: an in-office sociolinguistic study.

In-office conversations about hepatitis C can impact patients' perceptions of outcomes, as well as medication adherence. This study analyzed interactions between physicians, nonphysician healthcare providers (including nurses), and patients with hepatitis C virus infection in order to examine differences based on number and type of providers participating. Gastroenterologists, nonphysician healthcare providers, and patients with hepatitis C virus infection were video- and audio-recorded during regularly scheduled visits. Recordings were transcribed and analyzed using validated sociolinguistic techniques. Thirty-four visits took place with a physician only, 4 with a nonphysician healthcare provider only, and 25 with both providers (9 concurrent and 16 consecutive). Differences among the participant schema included visit length, patient "talk-time," and motivation provided. When providers saw patients consecutively, differing information was sometimes provided. In visits where providers saw the patient concurrently, competing authority between providers and exclusion of the patient through use of medical jargon were obstacles to ideal communication. Differences in hepatitis C-related interactions based on the number and type of participants suggest opportunities for improved communication. In visits with multiple providers, physicians and nurses should attempt to ensure that they (a) avoid supplying differing information, (b) present a "unified front" to avoid competing authority, and (c) minimize the use of medical jargon, which excludes patients from participating in their own healthcare.

Provider-patient in-office discussions of response to hepatitis C antiviral therapy and impact on patient comprehension.

BACKGROUND & AIMS: Providers need to communicate projected response rates effectively to enable patients with hepatitis C virus to make informed decisions about therapy. This study used interactional sociolinguistics (1) to evaluate how gastroenterologists and allied health professionals communicate information regarding response rates to antiviral therapy, (2) to determine how these discussions relate to where the patient is in the continuum of evaluation and treatment, (3) to assess whether patients were aligned with providers in their perceptions of response rates after office visits, and (4) to identify factors that improve provider-patient alignment. METHODS: Gastroenterologists, allied health professionals, and patients with hepatitis C virus were videotaped and audiotaped during regularly scheduled visits. Postvisit interviews were conducted separately with patients and providers. Visits and postvisits were transcribed and analyzed using validated sociolinguistic techniques. RESULTS: The phase of hepatitis C virus treatment shaped the benchmarks of response talk, although across the treatment continuum providers overwhelmingly made strategic use of positive statistics, providing motivation. In postvisit interviews, 55% of providers and patients were aligned on response rates. Patients with a favorable outcome and patients who asked response-related questions in the visit were more likely to be aligned with providers. Areas identified for improvement included the tendency to discuss response rates before an individualized assessment could be made, balancing motivation and accuracy, and assessing the patient's perspective before delivering any bad news, if necessary. CONCLUSIONS: Sociolinguistic analysis provides a powerful tool to evaluate provider-patient interactions and to identify ways to improve in-office communication regarding antiviral therapy.

Symptoms and signs in particular: the influence of the medical concern on the shape of physician-patient talk.

Talk between physicians and their patients has been shown to be shaped by participant characteristics,phase of the visit, and professional and institutional constraints. Surprisingly, the medical concern that brings the participants together has not been systematically and thoroughly investigated as a shaping influence on such talk. Based on a synthesis of separate interactional sociolinguistic studies of ten different medical concerns involving 395 patients and 105 physicians, I identify seven major differences across medical issues that may shape physician-patient discourse. In this paper I then focus on the first of these seven--the indication of the medical problem. Beginning with the traditional medical distinction between symptoms and signs, I characterize the kinds of evidence introduced by physicians and patients in talk about medical concerns. I then turn to the fuller discourse context of these reports, specifically examining how the indications emerge and play themselves out in the visit. Following Becker (1995b), I identify a two-step 'attunement' process, in which one participant (1) uses language to move toward a clearer understanding of the other's evidence and then displays this emerging understanding, and (2) takes up a stance toward the other's evidence--either corroborating or dismissing it with evidence of his or her own. In closing, I argue the importance of considering the shaping influences of differences across medical concerns, both for discourse analysts in their quest to account for particularities within physician-patient discourse as well as for healthcare professionals who believe that more attuned communication practices can result in better medical practices.

"People Say It's a Little Uncomfortable": Prenatal Genetic Counselors' Use of Constructed Dialogue to Reference Procedural Pain.

Prenatal genetic counseling involves an exchange of information between counselors and clients, including verbal descriptions of the potential pain of invasive prenatal diagnosis procedures such as amniocentesis. This paper describes the use of one linguistic feature in one context. It considers how two counselors describe procedural pain in 17 prenatal genetic counseling sessions, audiotaped as part of a larger data-driven study using sociolinguistic methodologies to characterize the discourse of genetic counseling. Analysis reveals that "constructed dialogue," or reporting something another person said, is a strategy used frequently by the counselors for describing procedural pain. Examination of the content and form of the constructed dialogue uncovered three recurring patterns that relate to its functions in the sessions: (1) inclusion of colloquial vocabulary; (2) references to common experiences through similes; and (3) explicit downplaying of pain. This analysis suggests that the naturally occurring phenomenon of quoting the words of others can be used in genetic counseling to impart information while simultaneously reassuring the client and creating counselor-client rapport. The complex relationship between the use of constructed dialogue and the enactment of genetic counseling principles through talk is also discussed.