Relationship Between Clinician Language and the Success of Behavioral Weight Loss Interventions : A Mixed-Methods Cohort Study.

BACKGROUND: International guidelines recommend that primary care clinicians recognize obesity and offer treatment opportunistically, but there is little evidence on how clinicians can discuss weight and offer treatment in ways that are well received and effective. OBJECTIVE: To examine relationships between language used in the clinical visit and patient weight loss. DESIGN: Mixed-methods cohort study. SETTING: 38 primary care clinics in England participating in the Brief Intervention for Weight Loss trial. PARTICIPANTS: 246 patients with obesity seen by 87 general practitioners randomly sampled from the intervention group of the randomized clinical trial. MEASUREMENTS: Conversation analysis of recorded discussions between 246 patients with obesity and 87 clinicians regarding referral to a 12-week behavioral weight management program offered as part of the randomized clinical trial. Clinicians' interactional approaches were identified and their association with patient weight loss at 12 months (primary outcome) was examined. Secondary outcomes included patients' agreement to attend weight management, attendance, loss of 5% body weight, actions taken to lose weight, and postvisit satisfaction. RESULTS: Three interactional approaches were identified on the basis of clinicians' linguistic and paralinguistic practices: creating a sense of referrals as "good news" related to the opportunity of the referral (n = 62); "bad news," focusing on the harms of obesity (n = 82); or neutral (n = 102). Outcome data were missing from 57 participants, so weighted analyses were done to adjust for missingness. Relative to neutral news, good news was associated with increased agreement to attend the program (adjusted risk difference, 0.25 [95% CI, 0.15 to 0.35]), increased attendance (adjusted risk difference, 0.45 [CI, 0.34 to 0.56]), and weight change (adjusted difference, -3.60 [CI, -6.58 to -0.62]). There was no evidence of differences in mean weight change comparing bad and neutral news, and no evidence of differences in patient satisfaction across all 3 approaches. LIMITATIONS: Data were audio only, so body language and nonverbal cues could not be assessed. There is potential for selection bias and residual confounding. CONCLUSION: When raising the topic of excess weight in clinical visits, presenting weight loss treatment as a positive opportunity is associated with greater uptake of treatment and greater weight loss. PRIMARY FUNDING SOURCE: National Institute for Health and Care Research School for Primary Care Research and the Foundation for the Sociology of Health and Illness.

The Basis of Patient Resistance to Opportunistic Discussions About Weight in Primary Care.

Clinicians expect that talking to patients with obesity about potential/future weight loss will be a difficult conversation, especially if it is not the reason that a patient is seeking medical help. Despite this expectation, many governments ask clinicians to take every opportunity to talk to patients about weight to help manage increasing levels of obesity. Although this is recommended, little is known about what happens in consultations when clinicians opportunistically talk to patients about weight, and if the anticipated difficulties are reality. This paper examines displays of explicit patient resistance following opportunistic weight-loss conversations initiated by GPs. We analyzed audio recordings and transcribed them for conversation analysis. We focused on the precursors of explicit resistance displays during opportunistic weight loss discussions, the format of the resistance, and the ways it was managed by GPs. We found relatively few instances of explicit resistance displays. When it did occur, rather than be related to the opportunistic nature of the advice, or the topic of weight itself, resistance was nuanced and associated to the sensitivity of the GPs managing unknown patient levels of awareness of weight loss benefits, or prior efforts to lose weight. Clinicians tended not to challenge this resistance from patients, and we suggest this tactic may be acceptable to patients and help foster the long-term collaborative relationships needed to tackle obesity. Data are in British English.

Beyond Single-Mindedness: A Figure-Ground Reversal for the Cognitive Sciences.

A fundamental fact about human minds is that they are never truly alone: all minds are steeped in situated interaction. That social interaction matters is recognized by any experimentalist who seeks to exclude its influence by studying individuals in isolation. On this view, interaction complicates cognition. Here, we explore the more radical stance that interaction co-constitutes cognition: that we benefit from looking beyond single minds toward cognition as a process involving interacting minds. All around the cognitive sciences, there are approaches that put interaction center stage. Their diverse and pluralistic origins may obscure the fact that collectively, they harbor insights and methods that can respecify foundational assumptions and fuel novel interdisciplinary work. What might the cognitive sciences gain from stronger interactional foundations? This represents, we believe, one of the key questions for the future. Writing as a transdisciplinary collective assembled from across the classic cognitive science hexagon and beyond, we highlight the opportunity for a figure-ground reversal that puts interaction at the heart of cognition. The interactive stance is a way of seeing that deserves to be a key part of the conceptual toolkit of cognitive scientists.

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.

Open science communication: The first year of the UK's Independent Scientific Advisory Group for Emergencies.

The COVID-19 pandemic has shone a light on the complex relationship between science and policy. Policymakers have had to make decisions at speed in conditions of uncertainty, implementing policies that have had profound consequences for people's lives. Yet this process has sometimes been characterised by fragmentation, opacity and a disconnect between evidence and policy. In the United Kingdom, concerns about the secrecy that initially surrounded this process led to the creation of Independent SAGE, an unofficial group of scientists from different disciplines that came together to ask policy-relevant questions, review the evolving evidence, and make evidence-based recommendations. The group took a public health approach with a population perspective, worked in a holistic transdisciplinary way, and were committed to public engagement. In this paper, we review the lessons learned during its first year. These include the importance of learning from local expertise, the value of learning from other countries, the role of civil society as a critical friend to government, finding appropriate relationships between science and policy, and recognising the necessity of viewing issues through an equity lens.

The interactional production and breach of new norms in the time of COVID-19: Achieving physical distancing in public spaces.

A key requirement of COVID-19 pandemic behavioural regulations in many countries was for people to 'physically distance' from one another, which meant departing radically from established norms of everyday human sociality. Previous research on new norms has been retrospective or prospective, focusing on reported levels of adherence to regulations or the intention to do so. In this paper, we take an observational approach to study the embodied and spoken interactional practices through which people produce or breach the new norm. The dataset comprises 20 'self-ethnographic' fieldnotes collected immediately following walks and runs in public spaces between March and September 2020, and these were analysed in the ethnomethodological tradition. We show that and how the new norm emerged through the mutual embodied and spoken conduct of strangers in public spaces. Orientations to the new norm were observed as people torqued their bodies away from each other in situations where there was insufficient space to create physical distance. We also describe how physical distance was produced unilaterally or was aggressively resisted by some people. Finally, we discuss the practical and policy implications of our observations both for deciding what counts as physical distancing and how to support the public to achieve it.

What happens when patients say "no" to offers of referral for weight loss? - Results and recommendations from a conversation analysis of primary care interactions.

OBJECTIVE: Guidelines recommend that clinicians should offer patients with obesity referrals to weight management services. However, clinicians and patients worry that such conversations will generate friction, and the risk of this is greatest when patients say no. We examined how doctors actually respond to patient refusals, and how patients reacted to clinicians in turn. METHODS: Conversation analysis of 226 GP-patient interactions recorded during a clinical trial of weight management referrals in UK primary care. RESULTS: Some clinicians responded to refusals by delivering further information or offering referral again. These actions treated patient refusals as unwelcome, and acted to pursue acceptance instead. However, pursuit did not lead to acceptance. Rather, pursuing acceptance lengthened consultations and led to frustration, offence, or anger. Clinicians who accepted refusals and closed the consultation avoided friction and negative emotional displays. CONCLUSION: Patient refusals have the potential to create negative consequences in the consultation and clinician responses were key in avoiding these. When clinicians acknowledged the legitimacy of patient refusals, negative consequences were avoided, and the conversation was briefer and smoother. PRACTICE IMPLICATIONS: When patients refuse the offer of a free weight management referral, GPs should accept this refusal, rather than trying to persuade patients to accept.

Discussing weight loss opportunistically and effectively in family practice: a qualitative study of clinical interactions using conversation analysis in UK family practice.

BACKGROUND: GPs are encouraged to make brief interventions to support weight loss, but they report concern about these conversations, stating that they need more details on what to say. Knowing how engage in these conversations could encourage GPs to deliver brief interventions for weight loss more frequently. OBJECTIVE: To examine which specific words and phrases were successful in achieving conversational alignment and minimizing misunderstanding, contributing to effective interventions. METHODS: A conversation analysis of English family practice patients participating in a trial of opportunistic weight-management interventions, which incorporated the offer of referral to community weight-management services (CWMS). Qualitative conversation analysis was applied to 246 consultation recordings to identify communication patterns, which contributed to clear, efficient interventions. RESULTS: Analysis showed variation in how GPs delivered interventions. Some ways of talking created misunderstandings or misalignment, while others avoided these. There were five components of clear and efficient opportunistic weight-management referrals. These were (i) exemplifying CWMS with a recognizable brand name (ii) saying weight-management 'programme' or 'service', rather than 'group' or 'club' (iii) stating that the referral is 'free' early on (iv) saying the number CWMS visits available on referral (v) stating that the CWMS programme available was 'local'. CONCLUSIONS: When making a brief opportunistic intervention to support weight loss, clinicians can follow these five steps to create a smooth and efficient intervention. Knowing this may allay clinicians' fears about these consultations being awkward and improve adherence to guidelines.

Vocabularies of social influence: Managing the moral accountability of influencing another.

While there are many definitions and conceptual accounts of 'persuasion' and other forms of social influence, social scientists lack empirical insight into how and when people actually use terms like 'persuade', 'convince', 'change somebody's mind' - what we call the vocabularies of social influence - in actual social interaction. We collected instances of the spontaneous use of these and other social influence terms (such as 'schmoozing' and 'hoodwinking') in face-to-face and telephone conversations across multiple domestic and institutional settings. The recorded data were transcribed and analysed using discursive psychology and conversation analysis with a focus on the actions accomplished in and through the use of social influence terms. We found that when speakers use 'persuading' - but not 'convincing' or 'changing somebody's mind' - it is in the service of orienting to the moral accountability of influencing others. The specificity with which social actors deploy these terms demonstrates the continued importance of developing our understandings of the meaning of words - especially psychological ones - via their vernacular use by ordinary people in the first instance, rather than have psychologists reify, operationalize, and build an architecture for social psychology without paying attention to what people actually do with the 'psychological thesaurus'.

Documentation in the neonatal unit: The support given to parents and their participation in their baby's care.

AIMS: The aim of this study was to explore how often the participation of parents in their infants' care and professionals' support for parents was documented in the clinical records and to determine how such participation and support were documented. BACKGROUND: Comprehensive documentation can facilitate collaboration between parents and healthcare professionals, supporting family-centred care, yet little is known about how this is reflected in practice. DESIGN: A prospective, mixed methods approach was used to analyse the clinical records of newborns. METHODS: The study was carried out in a large tertiary Neonatal Unit in the United Kingdom, from 2013 - 2014. We analysed the clinical records of 24 critically ill newborns using content analysis and thematic analysis, enabling us to determine the frequency of documented support and participation and how support and participation were documented. RESULTS: We identified four categories of support in the clinical records: "emotional", "spiritual", "social" and "practical support". We also identified instances where parents were encouraged to participate in their infant's care. Frequency differences in the documentation of support between infants facing a redirection of care decision and infants receiving active treatment were found. Two organisational themes were identified: "task focused documentation" and "minimal documentation of parental role". These were grouped together under the global theme "professional accountability". The perspectives and experiences of parents were minimally documented throughout. CONCLUSION: Documentation of support towards parents and parents' participation in their infants' care was limited in terms of frequency and content. Encouraging regular, detailed documentation of these aspects of care may facilitate family-centred care.

GP-delivered brief weight loss interventions: a cohort study of patient responses and subsequent actions, using conversation analysis in UK primary care.

BACKGROUND: Guidelines encourage GPs to make brief opportunistic interventions to support weight loss. However, GPs fear that starting these discussions will lead to lengthy consultations. Recognising that patients are committed to take action could allow GPs to shorten brief interventions. AIM: To examine which patient responses indicated commitment to action, and the time saved if these had been recognised and the consultation closed sooner. DESIGN AND SETTING: A mixed-method cohort study of UK primary care patients participating in a trial of opportunistic weight management interventions. METHOD: Conversation analysis was applied to 226 consultation audiorecordings to identify types of responses from patients that indicated that an offer of referral to weight management was well received. Odds ratios (OR) were calculated to examine associations between response types and likelihood of weight management programme attendance. RESULTS: Affirmative responses, for example 'yes', displayed no conversational evidence that the referral was well received and showed no association with attendance: 'yes' (OR 1.2, 95% confidence interval [CI] = 0.37 to 3.95, P = 0.97). However, 'oh'-prefaced responses and marked positive responses, for example 'lovely', showed conversational evidence of enthusiasm and were associated with higher odds of commercial weight management service attendance. Recognising these could have saved doctors a mean of 31 seconds per consultation. CONCLUSION: When doctors make brief opportunistic interventions that incorporate the offer of help, 'oh'-prefaced or marked positive responses indicate enthusiastic acceptance of the offer and a higher likelihood of take-up. Recognising these responses and moving swiftly to facilitate patient action would shorten the brief intervention in many cases.

Short-term outcome of treatment limitation discussions for newborn infants, a multicentre prospective observational cohort study.

OBJECTIVE: To determine the short-term outcomes of babies for whom clinicians or parents discussed the limitation of life-sustaining treatment (LST). DESIGN: Prospective multicentre observational study. SETTING: Two level 3, six level 2 and one level 1 neonatal units in the North-East London Neonatal Network. PARTICIPANTS: A total of 87 babies including 68 for whom limiting LST was discussed with parents and 19 babies died without discussion of limiting LST in the labour ward or neonatal unit. OUTCOME MEASURES: Final decision reached after discussions about limiting LST and neonatal unit outcomes (death or survived to discharge) for babies. RESULTS: Withdrawing LST, withholding LST and do not resuscitate (DNR) order was discussed with 48, 16 and 4 parents, respectively. In 49/68 (72%) cases decisions occurred in level 3 and 19 cases in level 2 units. Following the initial discussions, 34/68 parents made the decision to continue LST. In 33/68 cases, a second opinion was obtained. The parents of 14/48 and 2/16 babies did not agree to withdraw and withhold LST, respectively. Forty-seven out of 87 babies (54%) died following limitation of LST, 28/87 (32%) died receiving full intensive care support, 5/87 (6%) survived following a decision to limit LST and 7/87 (8%) babies survived following decision to continue LST. CONCLUSIONS: A significant proportion of parents chose to continue treatment following discussions regarding limiting LST for their babies, and a proportion of these babies survived to neonatal unit discharge. The long-term outcomes of babies who survive following limiting LST discussion need to be investigated.

A descriptive survey of cancer helplines in the United Kingdom: Who they are, the services offered, and the accessibility of those services.

BACKGROUND: There are more than 1500 UK health helplines in operation, yet we have scant knowledge about the resources in place to support the seeking and delivering of cancer-related telephone help and support. This research aimed to identify and describe cancer and cancer-related helpline service provision: the number of helplines available, the variety of services provided, and the accessibility of those services. METHOD: This study used online national questionnaire survey sent to 95 cancer and cancer-related helplines in the United Kingdom. RESULTS: A total of 69 (73%) of 95 surveyed cancer and cancer-related helplines completed the survey. Most helplines/organizations were registered charities, supported by donations; 73.5% of helplines had national coverage. Most helplines served all age-groups, ethnic groups, and men and women. Only 13.4% had a number that was free from landlines and most mobile networks, and 56.6% could only be contacted during working hours. More than 50% of helplines reported no provisions for callers with additional needs, and 55% had no clinical staff available to callers. Ongoing support and training for helpline staff was available but variable. CONCLUSION: Although cancer helplines in the United Kingdom offer reasonably broad coverage across the country, there are still potential barriers to accessibility. There are also opportunities to optimize the training of staff/volunteers across the sector. There are further prospects for helplines to enhance services and sustain appropriate and realistic quality standards.

Parental involvement in neonatal critical care decision-making.

The article analyses the decision-making process between doctors and parents of babies in neonatal intensive care. In particular, it focuses on cases in which the decision concerns the redirection of care from full intensive care to palliative care at the end of life. Thirty one families were recruited from a neonatal intensive care unit in England and their formal interactions with the doctor recorded. The conversations were transcribed and analysed using conversation analysis. Analysis focused on sequences in which decisions about the redirection of care were initiated and progressed. Two distinct communicative approaches to decision-making were used by doctors: 'making recommendations' and 'providing options'. Different trajectories for parental involvement in decision-making were afforded by each design, as well as differences in terms of the alignments, or conflicts, between doctors and parents. 'Making recommendations' led to misalignment and reduced opportunities for questions and collaboration; 'providing options' led to an aligned approach with opportunities for questions and fuller participation in the decision-making process. The findings are discussed in the context of clinical uncertainty, moral responsibility and the implications for medical communication training and guidance. A Virtual Abstract of this paper can be accessed at: https://www.youtube.com/watch?v=MyuymxDNupk&feature=youtu.be.

Calling the GP surgery: patient burden, patient satisfaction, and implications for training.

BACKGROUND: Good communication is central to the effectiveness of GP service provision, as well as to patient satisfaction with surgeries, but very little is known about the actual communication that occurs between patients and surgeries. AIM: This study was carried out to examine, for the first time, how receptionists interact with patients on the telephone, to identify features of communication associated with efficacy and patient satisfaction. DESIGN AND SETTING: A qualitative conversation analysis of incoming patient telephone calls, recorded 'for training purposes', in three English GP surgeries. METHOD: Data were analysed qualitatively to identify effective communication, then coded to establish the relative prevalence of communication types across each surgery. RESULTS: Analysis identified a burden on patients to drive calls forward and achieve service. 'Patient burden' occurred when receptionists failed to offer alternatives to patients whose initial requests could not be met, or to summarise relevant next actions (for example, appointment, call-back, or other query) at the end of calls. Coding revealed that 'patient burden' frequency differed across the services. Increased 'patient burden' was associated with decreased satisfaction on published satisfaction survey scores. CONCLUSION: Patients in some practices have to push for effective service when calling GP surgeries. Conversation analysis specifies what constitutes (in)effective communication. Findings can then underpin receptionist training and improve patient experience and satisfaction.

Patient burden during appointment-making telephone calls to GP practices.

OBJECTIVE: This study addresses, for the first time, the effectiveness of receptionists handling incoming calls from patients to access General Practice services. METHODS: It is a large-scale qualitative study of three services in the UK. Using conversation analysis, we identified the issue of 'patient burden', which we defined based on the trouble patients display pursuing service. We quantified instances of 'patient burden' using a coding scheme. RESULTS: We demonstrate how 'patient burden' unfolds in two phases of the telephone calls: (i) following an initial rejection of a patient's request; and (ii) following a receptionist's initiation of call closing. Our quantitative analysis shows that the three GP services differ in the frequency of 'patient burden' and reveals a correlation between the proportion of 'patient burden' and independent national satisfaction scores for these surgeries. CONCLUSION: Unlike post-hoc surveys, our analysis of live calls identifies the communicative practices which may constitute patient (dis)satisfaction. PRACTICE IMPLICATIONS: Through establishing what receptionists handle well or less well in encounters with patients, we propose ways of improving such encounters through training or other forms of intervention.

Can People With Intellectual Disability Resist Implications of Fault When Police Question Their Allegations of Sexual Assault and Rape?

When people alleging sexual assault are interviewed by police, their accounts are tested to see if they would stand up in court. Some tests are in the form of tendentious questions carrying implications (e.g., that the sex was consensual) damaging to the complainant's allegation. In a qualitative analysis of 19 English police interviews with people with intellectual disability (ID) defined in a variety of ways, we show how people with ID deal with the pragmatic complexity of such tendentious questions. We give examples in which the complainants detect and resist the questions' damaging implications; but we focus on occasions when the complainants do not do so. We discuss the use of tendentious questions in the light of national United Kingdom guidelines on the treatment of vulnerable witnesses.