Limited health literacy in primary care physiotherapy: Does a physiotherapist use techniques to improve communication?

OBJECTIVES: Research shows that health professionals should adapt their communication when addressing patients with limited health literacy (HL). However, the extent to which physiotherapists apply recommended communication techniques is unclear. METHODS: We conducted a two phase mixed-method study, first holding focus group interviews among patients and experts on communication to explore the need for adjusted communication in physiotherapist-patient interaction. Second, we manually coded audio recordings of primary care physiotherapy consultations to investigate the extent to which physiotherapists applied these recommended communication techniques, and adjusted their communication towards patients with lower education. RESULTS: Focus group interviews identified four categories of communication elements: the teach-back method, medical jargon explanation, summarizing patient's narratives, and checking patient's understanding. In 50 audio recordings we identified 2670 clauses. We report limited use of the recommended communication techniques; the teach-back method was used in 2% of consultations (95%CI: 0.4%-10.5%) while medical jargon explanation was used in 84% (95%CI: 71.5%-91.7%). Mixed effects logistic regression models showed no association between lower education and communication techniques. CONCLUSION: Although physiotherapists need to adjust their communication to patients with lower education, they rarely apply the recommended communication techniques. PRACTICE IMPLICATIONS: Knowledge about limited HL among physiotherapists needs to be increased.

Coding linguistic elements in clinical interactions: a step-by-step guide for analyzing communication form.

BACKGROUND: The quality of communication between healthcare professionals (HCPs) and patients affects health outcomes. Different coding systems have been developed to unravel the interaction. Most schemes consist of predefined categories that quantify the content of communication (the what). Though the form (the how) of the interaction is equally important, protocols that systematically code variations in form are lacking. Patterns of form and how they may differ between groups therefore remain unnoticed. To fill this gap, we present CLECI, Coding Linguistic Elements in Clinical Interactions, a protocol for the development of a quantitative codebook analyzing communication form in medical interactions. METHODS: Analyzing with a CLECI codebook is a four-step process, i.e. preparation, codebook development, (double-)coding, and analysis and report. Core activities within these phases are research question formulation, data collection, selection of utterances, iterative deductive and inductive category refinement, reliability testing, coding, analysis, and reporting. RESULTS AND CONCLUSION: We present step-by-step instructions for a CLECI analysis and illustrate this process in a case study. We highlight theoretical and practical issues as well as the iterative codebook development which combines theory-based and data-driven coding. Theory-based codes assess how relevant linguistic elements occur in natural interactions, whereas codes derived from the data accommodate linguistic elements to real-life interactions and contribute to theory-building. This combined approach increases research validity, enhances theory, and adjusts to fit naturally occurring data. CLECI will facilitate the study of communication form in clinical interactions and other institutional settings.

How General Practitioners Raise Psychosocial Concerns as a Potential Cause of Medically Unexplained Symptoms: A Conversation Analysis.

A common explanation for medically unexplained symptoms (MUS) relates patients' psychosocial concerns to their physical ailments. The present study used conversation analysis to examine how general practitioners (GPs) ascribe psychosocial causes to patients' unexplained symptoms during medical consultations. Our data consisted of 36 recorded consultations from Dutch general practice. We found that GPs raise psychosocial concerns as a potential cause of MUS in 14 consultations, either captured in 1) history-taking questions, or 2) diagnostic explanations. Whereas questions invited patient ideas, explanations did not make relevant patient responses in adjacent turns and subordinated patients' knowledge in symptom experiences to the GP's medical expertise. By questioning patients whether their symptoms may have psychosocial causes GPs enabled symptom explanations to be constructed collaboratively. Furthermore, additional data exploration showed that GPs lay ground for psychosocial ascriptions by first introducing psychosocial concerns as a consequence rather than a cause of complaints. Such preliminary activities allowed GPs to initiate rather delicate psychosocial ascriptions later in the consultation.

Unexplained versus explained symptoms: The difference is not in patients' language use. A quantitative analysis of linguistic markers.

OBJECTIVE: Patients with medically unexplained symptoms (MUS) are believed to have a deviant way of talking about complaints. This study systematically compared linguistic markers in symptom presentations of patients with MUS and medically explained symptoms (MES). METHODS: This content analysis (cross-sectional study) conceptualized relevant linguistic markers based on previous research about MUS communication. Linguistic markers included negations ("not"), intensifiers ("very"), diminishers ("a little"), first or third person subject ("I" vs. "my body"), subjectivity markers ("I think") and abstraction ("I'm gasping for breath" vs. "I'm short of breath"). We also coded valence, reference to physical or mental states, and consultation phase. We compared 41 MUS and 41 MES transcribed video-recorded general practice consultations. Data were analyzed with binary random intercepts models. RESULTS: We selected and coded 2752 relevant utterances. Patients with MUS used less diminishers compared to patients with MES, but this main effect disappeared when consultation phase was included as predictor. For all other linguistic variables, the analyses did not reveal any variation in language use based on whether patients had MUS or MES. Importantly, utterances' valence and reference to physical or mental state did predict the use of linguistic markers. CONCLUSION: We observed no systematic variations in linguistic markers for patients who suffered from MUS compared to MES. Patients varied their language use based on utterances' valence and reference to physical or mental states. Current ideas about deviant patient communication may be based on stigmatized perceptions of how patients with MUS communicate, rather than actual differences in their talk.

Linguistic and interactional aspects that characterize consultations about medically unexplained symptoms: A systematic review.

OBJECTIVE: The apparent absence of any specific underlying diseases challenges patient-provider communication about medically unexplained symptoms (MUS). Previous research focused on general communication patterns in these interactions; however, an overview of more detailed interactional and linguistic aspects is lacking. This review aims to gain a detailed understanding of communicative challenges in MUS consultations by synthesizing evidence from conversation and discourse analytic research. METHODS: A systematic review of publications using eight databases (PubMed, Embase, CINAHL, PsychINFO, Web of Science, MLA International Bibliography, LLBA and Communication Abstracts). Search terms included 'MUS', 'linguistics' and 'communication'. Additional studies were identified by contacting experts and searching bibliographies. We included linguistic and/or interactional analyses of natural patient-provider interactions about MUS. Two authors independently extracted the data, and quality appraisal was based on internal and external validity. RESULTS: We identified 18 publications that met the inclusion criteria. The linguistic and interactional features of MUS consultations pertained to three dimensions: 1) symptom recognition, 2) double trouble potential (i.e. patients and providers may have differing views on symptoms and differing knowledge domains), and 3) negotiation and persuasion (in terms of acceptable explanations and subsequent psychological treatment). We describe the recurrent linguistic and interactional features of these interactions. CONCLUSIONS: Despite the presence of a double trouble potential in MUS consultations, validation of symptoms and subtle persuasive conduct may facilitate agreement on illness models and subsequent (psychological) treatment.

Quantifying implicit uncertainty in primary care consultations: A systematic comparison of communication about medically explained versus unexplained symptoms.

OBJECTIVE: General practitioners (GPs) disclose more uncertainty (e.g. "I don't know") in consultations with patients presenting medically unexplained symptoms (MUS) versus medically explained symptoms (MES), which could negatively affect patient outcomes. This study assessed if this pattern also holds for more subtle, implicit uncertainty expressions (e.g. "maybe", "might") during different consultation phases, and assessed their relation to patient pre-post consultation anxiety. METHODS: We quantified implicit markers of uncertainty of 18 GPs in 82 consultations about MUS or MES during different consultation phases. Relative frequencies of implicit uncertainty per consultation were regressed on differences in momentary anxiety pre and post consultation. RESULTS: We coded 2590  GP utterances. Uncertainty expressions were more frequent in MUS versus MES consultations (OR = 1.54, p = .004), especially during diagnosis and treatment recommendations compared to physical examinations (OR =0 .45, p = .001). Implicit uncertainty was not related to patients' changes in anxiety (b = -0.11, p = .817). CONCLUSIONS: GPs express more uncertainty during MUS (versus MES) consultations, especially during the diagnostic phase and treatment recommendations. This does not necessarily affect patient anxiety. PRACTICE IMPLICATIONS: Implicit uncertainty expressions reflect the mere complexity of communicating a medically unexplained diagnosis, which does not affect patient anxiety.

Quantifying positive communication: Doctor's language and patient anxiety in primary care consultations.

OBJECTIVE: Positive communication is advocated for physicians during consultations with patients presenting medically unexplained symptoms (MUS), but studies generally focus on what is said rather than how it is said. This study quantified language use differences of general practitioners (GPs), and assessed their relation to patient anxiety. METHODS: Language use of 18 Dutch GPs during 82 consultations was compared for patients with MUS versus medically explained symptoms (MES). Message content (positive or negative) was differentiated from its directness (direct or indirect), and related to changes in patient's state anxiety (abbreviated State Trait Anxiety Inventory; STAI). RESULTS: In total, 2590 clauses were identified. GPs approached patients with MES with relatively more direct (vs. indirect) positive and indirect (vs. direct) negative messages (OR 1.91, 95% CI 1.42-2.59). Anxiety of both patient groups increased when GPs used more direct (vs. indirect) negative messages (b = 0.67, 95% CI 0.07-1.27) CONCLUSIONS: GPs use different language depending on the content of messages for patients with MES, but not MUS. Direct negative messages relate to an increase in patient anxiety. PRACTICE IMPLICATIONS: GPs could manage patient's state anxiety by expressing negative messages in an indirect rather than direct manner.