Opportunities for primary health care: a qualitative study of perinatal health and wellbeing during bushfire crises.

BACKGROUND: During the summer of 2019/2020, Australia experienced a catastrophic wildfire season that affected nearly 80% of Australians either directly or indirectly. The impacts of climate crisis on perinatal health have only recently begun to receive attention. The objective of this study was to understand experiences of perinatal women during the bushfire and smoke events of 2019-2020 regarding health, health care, and public health messaging. METHODS: Semistructured interviews were conducted by phone or web conferencing platforms with 43 participants living in the south-east of Australia who were either pregnant or who had recently had a baby during the 2019/2020 fires. RESULTS: The health impacts on participants of the fires, associated smoke, and evacuations for some, were both physical and psychological. Many participants sought information regarding how to protect their own health and that of their unborn/recently born children, but reported this difficult to find. CONCLUSIONS: Pregnant women and new mothers exposed to bushfire events are a risk group for adverse physical and psychological outcomes. At the time of the 2019/2020 Australian bushfires, exposed women could not easily access evidence-based information to mitigate this risk. Family practitioners are well placed to provide pregnant women and new mothers with this sought-after information, but they need to be prepared well in advance of future similar events.

Messengers of stress: Towards a cortisol sociology.

In 2008, Timmermans and Haas called for a 'sociology of disease' to develop and challenge the sociology of health and illness. A sociology of disease, they argued, would take seriously the biological and physiological processes of disease in theorising health and illness. Building on two decades of Science and Technology Studies and feminist work on biological actors such as hormones and genes, we propose a 'cortisol sociology' to push further at this argument. As a 'messenger of stress', cortisol is key to understanding human and non-human health as a biosocial phenomenon. We argue that sociologists should engage with cortisol through critical yet open-minded reading of the relevant science and critical triangulation studies, and by tracking cortisol's movements from science into public worlds of biosensing and self-monitoring.

Sociolinguistic factors affecting performance in the Clinical Skills Assessment of the MRCGP: a mixed-methods approach.

BACKGROUND: Differential performance in clinical skills assessments is a widespread phenomenon, for which there remain few explanations. AIM: To better understand the conversational contexts of simulated consultations and how candidates actually behave in these consultations and to determine sociolinguistic factors for high- and low-performing candidates. DESIGN & SETTING: Taking the Membership of the Royal College of General Practitioners' (MRCGP) clinical skills assessment (CSA) examination as a model, this research applied sociolinguistic analyses to case videos of 198 consecutive candidates presenting for the CSA examination. METHOD: Using a mixed-methods approach, both quantitative and qualitative sociolinguistics methodologies were combined to analyse video consultations, and findings were compared with those from group discussions with MRCGP examiners. RESULTS: There is more 'talk' in simulated consultations than in real life. On macroanalysis, there was little difference between poor- and well-performing candidates. However, microanalysis found subtle differences in structuring consultations, metacommunication, picking up cues, and misunderstandings with and giving explanations to patients. Formulaic talk, contrary to examiners' perceptions was more common in successful candidates, but it was personalised and sited appropriately in the consultation. CONCLUSION: This is an interactionally demanding form of clinical assessment, that requires giving support to candidates and a more analytic approach to the development of interpersonal skills. Sociolinguistic features of consulting to help trainers and candidates prepare for the CSA are identified.

Simulated consultations: a sociolinguistic perspective.

BACKGROUND: Assessment of consulting skills using simulated patients is widespread in medical education. Most research into such assessment is sited in a statistical paradigm that focuses on psychometric properties or replicability of such tests. Equally important, but less researched, is the question of how far consultations with simulated patients reflect real clinical encounters--for which sociolinguistics, defined as the study of language in its socio-cultural context, provides a helpful analytic lens. DISCUSSION: In this debate article, we draw on a detailed empirical study of assessed role-plays, involving sociolinguistic analysis of talk in OSCE interactions. We consider critically the evidence for the simulated consultation (a) as a proxy for the real; (b) as performance; (c) as a context for assessing talk; and (d) as potentially disadvantaging candidates trained overseas. Talk is always a performance in context, especially in professional situations (such as the consultation) and institutional ones (the assessment of professional skills and competence). Candidates who can handle the social and linguistic complexities of the artificial context of assessed role-plays score highly--yet what is being assessed is not real professional communication, but the ability to voice a credible appearance of such communication. Fidelity may not be the primary objective of simulation for medical training, where it enables the practising of skills. However the linguistic problems and differences that arise from interacting in artificial settings are of considerable importance in assessment, where we must be sure that the exam construct adequately embodies the skills expected for real-life practice. The reproducibility of assessed simulations should not be confused with their validity. Sociolinguistic analysis of simulations in various professional contexts has identified evidence for the gap between real interactions and assessed role-plays. The contextual conditions of the simulated consultation both expect and reward a particular interactional style. Whilst simulation undoubtedly has a place in formative learning for professional communication, the simulated consultation may distort assessment of professional communication These sociolinguistic findings contribute to the on-going critique of simulations in high-stakes assessments and indicate that further research, which steps outside psychometric approaches, is necessary.

Ovulation monitoring and reproductive heterosex: living the conceptive imperative?

Using biosensors, or devices that provide biological information to users about their own bodies, to map ovulation and time intercourse is a practice of rising significance in economically privileged countries. Based on an ethnographic study of ovulation biosensing, this paper explores the contradictions between device manufacturers' figurations of reproductive heterosex as a natural and pleasurable experience facilitated by fertility monitoring technology, and heterosexual women users' accounts of the pleasures and difficulties of ovulation monitoring and associated sexual encounters. Drawing on Science and Technology Studies and the concept of 'script', we examine the frameworks of action defined by makers of ovulation biosensors and how these are accepted, refused or remade by users. Within the scientific romance configured by manufacturers, reproductive heterosex emerges as exciting and fun, whilst the hard, 'technical' work of conception is done by ovulation technologies. Yet ovulation monitoring is described by many heterosexual women users as an exciting and yet anxiety-producing practice through which they come to know their bodies differently, often through online discussions with other women. Living a 'conceptive imperative', women engaging with ovulation sensing reconfigure their reproductive embodiment and shift their relationship to male partners in ways that reveal heterosexual 'baby-making' as a complex and nuanced practice worthy of critical engagement.

Ethical implications of home telecare for older people: a framework derived from a multisited participative study.

CONTEXT: Telecare and telehealth developments have recently attracted much attention in research and service development contexts, where their evaluation has predominantly concerned effectiveness and efficiency. Their social and ethical implications, in contrast, have received little scrutiny. OBJECTIVE: To develop an ethical framework for telecare systems based on analysis of observations of telecare-in-use and citizens' panel deliberations. DESIGN: Ethnographic study (observation, work shadowing), interviews, older citizens' panels and a participative conference. SETTING: Participants' homes, workplaces and familiar community venues in England, Spain, the Netherlands and Norway 2008-2011. RESULTS: Older respondents expressed concerns that telecare might be used to replace face-to-face/hands-on care to cut costs. Citizens' panels strongly advocated ethical and social questions being considered in tandem with technical and policy developments. Older people are too often excluded from telecare system design, and installation is often wrongly seen as a one-off event. Some systems enhance self-care by increasing self-awareness, while others shift agency away from the older person, introducing new forms of dependency. CONCLUSIONS: Telecare has care limitations; it is not a solution, but a shift in networks of relations and responsibilities. Telecare cannot be meaningfully evaluated as an entity, but rather in the situated relations people and technologies create together. Characteristics of ethical telecare include on-going user/carer engagement in decision making about systems: in-home system evolution with feedback opportunities built into implementation. System design should be horizontal, 'two-way'/interactive rather than vertical or 'one-way'. An ethical framework for telecare has been developed from these conclusions (Table 1).

Beyond the 'dyad': a qualitative re-evaluation of the changing clinical consultation.

OBJECTIVE: To identify characteristics of consultations that do not conform to the traditionally understood communication 'dyad', in order to highlight implications for medical education and develop a reflective 'toolkit' for use by medical practitioners and educators in the analysis of consultations. DESIGN: A series of interdisciplinary research workshops spanning 12 months explored the social impact of globalisation and computerisation on the clinical consultation, focusing specifically on contemporary challenges to the clinician-patient dyad. Researchers presented detailed case studies of consultations, taken from their recent research projects. Drawing on concepts from applied sociolinguistics, further analysis of selected case studies prompted the identification of key emergent themes. SETTING: University departments in the UK and Switzerland. PARTICIPANTS: Six researchers with backgrounds in medicine, applied linguistics, sociolinguistics and medical education. One workshop was also attended by PhD students conducting research on healthcare interactions. RESULTS: The contemporary consultation is characterised by a multiplicity of voices. Incorporation of additional voices in the consultation creates new forms of order (and disorder) in the interaction. The roles 'clinician' and 'patient' are blurred as they become increasingly distributed between different participants. These new consultation arrangements make new demands on clinicians, which lie beyond the scope of most educational programmes for clinical communication. CONCLUSIONS: The consultation is changing. Traditional consultation models that assume a 'dyadic' consultation do not adequately incorporate the realities of many contemporary consultations. A paradox emerges between the need to manage consultations in a 'super-diverse' multilingual society, while also attending to increasing requirements for standardised protocol-driven approaches to care prompted by computer use. The tension between standardisation and flexibility requires addressing in educational contexts. Drawing on concepts from applied sociolinguistics and the findings of these research observations, the authors offer a reflective 'toolkit' of questions to ask of the consultation in the context of enquiry-based learning.

Ageing with telecare: care or coercion in austerity?

In recent years images of independence, active ageing and staying at home have come to characterise a successful old age in western societies. 'Telecare' technologies are heavily promoted to assist ageing-in-place and a nexus of demographic ageing, shrinking healthcare and social care budgets and technological ambition has come to promote the 'telehome' as the solution to the problem of the 'age dependency ratio'. Through the adoption of a range of monitoring and telecare devices, it seems that the normative vision of independence will also be achieved. But with falling incomes and pressure for economies of scale, what kind of independence is experienced in the telehome? In this article we engage with the concepts of 'technogenarians' and 'shared work' to illuminate our analysis of telecare in use. Drawing on European-funded research we argue that home-monitoring based telecare has the potential to coerce older people unless we are able to recognise and respect a range of responses including non-use and 'misuse' in daily practice. We propose that re-imagining the aims of telecare and redesigning systems to allow for creative engagement with technologies and the co-production of care relations would help to avoid the application of coercive forms of care technology in times of austerity.

Computer templates in chronic disease management: ethnographic case study in general practice.

OBJECTIVE: To investigate how electronic templates shape, enable and constrain consultations about chronic diseases. DESIGN: Ethnographic case study, combining field notes, video-recording, screen capture with a microanalysis of talk, body language and data entry-an approach called linguistic ethnography. SETTING: Two general practices in England. PARTICIPANTS AND METHODS: Ethnographic observation of administrative areas and 36 nurse-led consultations was done. Twenty-four consultations were directly observed and 12 consultations were video-recorded alongside computer screen capture. Consultations were transcribed using conversation analysis conventions, with notes on body language and the electronic record. The analysis involved repeated rounds of viewing video, annotating field notes, transcription and microanalysis to identify themes. The data was interpreted using discourse analysis, with attention to the sociotechnical theory. RESULTS: Consultations centred explicitly or implicitly on evidence-based protocols inscribed in templates. Templates did not simply identify tasks for completion, but contributed to defining what chronic diseases were, how care was being delivered and what it meant to be a patient or professional in this context. Patients' stories morphed into data bytes; the particular became generalised; the complex was made discrete, simple and manageable; and uncertainty became categorised and contained. Many consultations resembled bureaucratic encounters, primarily oriented to completing data fields. We identified a tension, sharpened by the template, between different framings of the patient-as 'individual' or as 'one of a population'. Some clinicians overcame this tension, responding creatively to prompts within a dialogue constructed around the patient's narrative. CONCLUSIONS: Despite their widespread implementation, little previous research has examined how templates are actually used in practice. Templates do not simply document the tasks of chronic disease management but profoundly change the nature of this work. Designed to assure standards of 'quality' care they contribute to bureaucratisation of care and may marginalise aspects of quality care which lie beyond their focus. Creative work is required to avoid privileging 'institution-centred' care over patient-centred care.

Telecare and older people: who cares where?

'Telecare solutions' are seen as a potential means of addressing the future care needs of ageing societies in Western economies. The development of these remote care systems runs in parallel with policies aimed at 'ageing in place'; and is targeted at supporting the perceived care needs of frail older people within the home. Drawing on ethnographic and deliberative panel data from European Community funded research, we consider how these developments contribute to a reshaping of the place and experience of care for older people. We do so by addressing the ways in which remote care systems can, firstly, act to change the experience of home; and secondly, re-order the place of care-work and responsibilities to care as new actors become enrolled within the care network and existing care-givers take on differing roles and responsibilities. Finally, we consider how this paper contributes to conceptual debates around institution and extitution - that is, the de-territorialisation of the physical structure of the institution and its re-manifestation through new spaces and times that seek to end interior and exterior distinctions.

Opening up the 'black box' of the electronic patient record: a linguistic ethnographic study in general practice.

One of the most pervasive changes in general practice is the introduction of the electronic patient record (EPR). The EPR supports both immediate clinical and anticipatory care (e.g. management of risk factors). Incorporating the EPR into social interaction is a complex task which is achieved discursively, clinician and patient responding to interactional contingencies as the consultation unfolds. Clinicians are presented with a 'dilemma of attention' as they seek to deal with the immediacy ('here and now') of the interpersonal interaction and the institutional demands ('there and then') of the EPR. We present data analysis which illuminates the EPR as an important presence in the clinic consultation context, one which places material and textual demands. Developing previous work on the triadic (three party) consultation, our novel multimodal analysis of the EPR-in-use suggests there is value in considering the EPR as a collection of silent but consequential voices. Micro-analytic attention to the way in which these different voices are managed, combined with understandings drawn from ethnographic observation of the primary care context, reveals the EPR as exhibiting a previously under-explored kind of 'agency' within the consultation.

Paid to share: IVF patients, eggs and stem cell research.

Following a recent decision by the human fertilisation and embryology authority (HFEA), British women undergoing in vitro fertilisation (IVF) treatment can be 'paid to share' their eggs with stem cell researchers. The HFEA and the clinic proposing the scheme present this as a 'win-win' arrangement benefiting both infertile women and couples and British science. It is also represented as concurrently both 'business as usual' and an exceptional case. Constituting a significant departure from the previous policy and practice of altruistic donation, the scheme has raised significant concerns among clinicians and activists. Here, we ask what questions feminists can bring to these debates without resorting to a position of either refusal or affirmation. Drawing on diverse materials from public debates, as well as social scientific literature on gamete and embryo donation, we undertake a close analysis of the discursive framing and justification of the proposal. We argue that these discourses are characterised by three linked areas of elision and distinction: treatment and research; eggs and embryos; and donation and selling. Our analysis highlights the need for innovative social, ethical and political consideration of egg sharing for stem cell research.

Explanations, explanations, explanations: how do patients with limited English construct narrative accounts in multi-lingual, multi-ethnic settings, and how can GPs interpret them?

BACKGROUND: The gap is widening between understanding the subtle ways patients and GPs manage their talk, and superficial discussion of the 'language barrier' among linguistic minority patients. All patients have to explain themselves, not just those for whom English is their first or main language. Patients' explanations reflect how they want the doctor to perceive them as a patient and as a person: they reveal patients' identities. Yet interpretations are not easy when patients' style of talking English is influenced by their first language and cultural background. OBJECTIVE: To explore in detail how patients with limited English and GPs jointly overcome misunderstandings in explanations. METHODS: Using discourse analysis and conversation analysis, we examine how GPs and their patients with limited English negotiate explanations and collaborate to manage, repair or prevent understanding problems. RESULTS: 31% of patients said English was not their first language. Misunderstandings arise owing to a range of linguistic and cultural factors, including stress and intonation patterns, vocabulary, the way a patient sequences their narrative, and patient and GP pursuing different agendas. CONCLUSION: When talk itself is the problem, patients' explanations can lead to misunderstandings, which GPs have to repair if they cannot prevent. Careful interpretation by skillful GPs can reveal patients' knowledge, experience and perspective.

Theme-oriented discourse analysis of medical encounters.

APPROACH: Theme-oriented discourse analysis looks at how language constructs professional practice. Recordings of naturally occurring interactions are transcribed and combined with ethnographic knowledge. Analytic themes drawn primarily from sociology and linguistics shed light on how meaning is negotiated in interaction. Detailed features of talk, such as intonation and choice of vocabulary, trigger inferences about what is going on and being talked about. These affect how interactants judge each other and decisions are made. Interactions also have larger rhetorical patterns used by both patients and doctors to persuade each other. EXAMPLES: Two settings are used to illustrate this approach: genetic counselling and primary care consultations in multilingual areas. In genetic counselling, interactions are organised around the tension between the risks of knowing and the risks of occurrence. This can lead to a 'rhetorical duel' between health professionals and patients and their families. In intercultural primary care settings, talk itself may be the problem when interpretive processes cannot be taken for granted. Even widely held models of good practice can lead to misunderstandings under these conditions. CONCLUSION; Through discourse analysis, the talk under scrutiny can be slowed down to show the interpretive processes and overall patterns of an activity. Discourse analysts and health professionals, working together, can look at problems in new ways and develop interventions and tools for a better understanding of communication in medical life.

Misunderstandings: a qualitative study of primary care consultations in multilingual settings, and educational implications.

BACKGROUND: Patients in inner-city areas come from increasingly diverse language and cultural backgrounds. Neither communications training modelled on local English speakers nor the provision of interpreters offer adequate solutions. AIM: To identify how patients with limited English and culturally different communication styles consult with general practitioners (GPs) in English, and to develop training strategies from both good practice and observed misunderstandings. METHODS: Randomly selected routine and emergency surgeries in 19 inner London general practices were video-recorded. The videos were viewed independently by 2 discourse analysts. Key consultations, across a wide range of English language ability, were selected and transcribed to analyse misunderstandings resulting from language/cultural differences. RESULTS: Of the 232 video recordings that were made, 20% were with patients with limited English and contained major and often extended misunderstandings. QUALITATIVE ANALYSIS: Four main categories of patient 'talk' contributing to misunderstandings are identified: (1) pronunciation and word stress; (2) intonation and speech delivery; (3) grammar, vocabulary and lack of contextual information; and (4) style of presentation. The importance of different styles of self-presentation by patients as the reason for misunderstandings is highlighted. On only 3 occasions were culturally specific health beliefs raised. CONCLUSION: It is routine for GPs in inner London practices to manage consultations with patients with culturally different communicative styles from their own. Specific training in identifying these problems and preventing/repairing them in the consultation is essential. This level of awareness-raising is more crucial than general discussions of culturally different health belief models.

Experiencing new forms of genetic choice: findings from an ethnographic study of preimplantation genetic diagnosis.

Contemporary scientific and clinical knowledges and practices continue to make available new forms of genetic information, and to create new forms of reproductive choice. For example, couples at high risk of passing on a serious genetic condition to their offspring in Britain today have the opportunity to use Preimplantation Genetic Diagnosis (PGD) to select embryos that are unaffected by serious genetic disease. This information assists these couples in making reproductive choices. This article presents an analysis of patients' experiences of making the decision to undertake PGD treatment and of making reproductive choices based on genetic information. We present qualitative interview data from an ethnographic study of PGD based in two British clinics which indicate how these new forms of genetic choice are experienced by patients. Our data suggest that PGD patients make decisions about treatment in a complex way, taking multiple variables into account, and maintaining ongoing assessments of the multiple costs of engaging with PGD. Patients are aware of broader implications of their decisions, at personal, familial, and societal levels, as well as clinical ones. Based on these findings we argue that the ethical and social aspects of PGD are often as innovative as the scientific and medical aspects of this technique, and that in this sense, science cannot be described as "racing ahead" of society.