The elicitation and management of multiple health concerns in GP consultations.

OBJECTIVE: To describe the nature of patient concerns and to explore if, when and how they are addressed by GPs in the UK. METHODS: Detailed coding and descriptive analysis of 185 video recordings from the EPaC study (Elicitation of Patient Concerns, EPaC) RESULTS: An average of 2.1 concerns were raised per consultation and the most common concerns were musculoskeletal, administrative (e.g. test results and medication related issues), and skin symptoms. GPs who had been trained as part of the EPaC intervention to solicit for additional concerns in the opening phase of the consultation did so 92.6% of the time. In contrast, those in the control arm did so only 7% of the time. However, the particular formulation of the GP soliciting question does not seem to be associated with the likelihood of the patient volunteering an additional concern. CONCLUSIONS: GP consultations are complex encounters in which multiple concerns are dealt with across a wide range of disease areas. GPs can be trained to solicit for problems/concerns early in the consultation. PRACTICE IMPLICATIONS: Soliciting for additional concerns is not routinely done. But very brief training can substantially help in eliciting concerns early in the consultation, which may help with organising the consultation.

Patients embodied and as-a-body within bedside teaching encounters: a video ethnographic study.

Bedside teaching encounters (BTEs) involve doctor-patient-student interactions, providing opportunities for students to learn with, from and about patients. How the differing concerns of patient care and student education are balanced in situ remains largely unknown and undefined. This video ethnographic study explores patient involvement during a largely student-centric activity: 'feedback sequences' where students learn clinical and practical skills. Drawing on a data subset from a multi-site study, we used Conversation Analysis to investigate verbal and non-verbal interactional practices to examine patients' inclusion and exclusion from teaching activities across 25 BTEs in General Practice and General Surgery and Medicine with 50 participants. Through analysis, we identified two representations of the patient: the patient embodied (where patients are actively involved) and the patient as-a-body (when they are used primarily as a prop for learning). Overall, patients were excluded more during physical examination than talk-based activities. Exclusion occurred through physical positioning of doctor-patient-student, and through doctors and students talking about, rather than to, patients using medical jargon and online commentaries. Patients' exclusion was visibly noticeable through eye gaze: patients' middle-distance gaze coincided with medical terminology or complex wording. Inclusory activities maintained the patient embodied during teaching activities through doctors' skilful embedding of teaching within their care: including vocalising clinical reasoning processes through students, providing patients with a 'warrant to listen', allocating turns-at-talk for them and eye-contact. This study uniquely demonstrates the visible nature patient exclusion, providing firm evidence of how this affects patient empowerment and engagement within educational activities for tomorrow's doctors.

Conversational assessment in memory clinic encounters: interactional profiling for differentiating dementia from functional memory disorders.

OBJECTIVES: In the UK dementia is under-diagnosed, there is limited access to specialist memory clinics, and many of the patients referred to such clinics are ultimately found to have functional (non-progressive) memory disorders (FMD), rather than a neurodegenerative disorder. Government initiatives on 'timely diagnosis' aim to improve the rate and quality of diagnosis for those with dementia. This study seeks to improve the screening and diagnostic process by analysing communication between clinicians and patients during initial specialist clinic visits. Establishing differential conversational profiles could help the timely differential diagnosis of memory complaints. METHOD: This study is based on video- and audio recordings of 25 initial consultations between neurologists and patients referred to a UK memory clinic. Conversation analysis was used to explore recurrent communicative practices associated with each diagnostic group. RESULTS: Two discrete conversational profiles began to emerge, to help differentiate between patients with dementia and functional memory complaints, based on (1) whether the patient is able to answer questions about personal information; (2) whether they can display working memory in interaction; (3) whether they are able to respond to compound questions; (4) the time taken to respond to questions; and (5) the level of detail they offer when providing an account of their memory failure experiences. CONCLUSION: The distinctive conversational profiles observed in patients with functional memory complaints on the one hand and neurodegenerative memory conditions on the other suggest that conversational profiling can support the differential diagnosis of functional and neurodegenerative memory disorders.

Towards diagnostic conversational profiles of patients presenting with dementia or functional memory disorders to memory clinics.

OBJECTIVE: This study explores whether the profile of patients' interactional behaviour in memory clinic conversations with a doctor can contribute to the clinical differentiation between functional memory disorders (FMD) and memory problems related to neurodegenerative diseases. METHODS: Conversation Analysis of video recordings of neurologists' interactions with patients attending a specialist memory clinic. "Gold standard" diagnoses were made independently of CA findings by a multi-disciplinary team based on clinical assessment, neuropsychological testing and brain imaging. RESULTS: Two discrete conversational profiles for patients with memory complaints emerged, including (i) who attends the clinic (i.e., whether or not patients are accompanied), and (ii) patients' responses to neurologists' questions about memory problems, such as difficulties with compound questions and providing specific and elaborated examples and frequent "I don't know" responses. CONCLUSION: Specific communicative difficulties are characteristic of the interaction patterns of patients with a neurodegenerative pathology. Those difficulties are manifest in memory clinic interactions with neurologists, thereby helping to differentiate patients with dementia from those with FMD. PRACTICAL IMPLICATIONS: Our findings demonstrate that conversational profiles based on patients' contributions to memory clinic encounters have diagnostic potential to assist the screening and referral process from primary care, and the diagnostic service in secondary care.

Feedback in action within bedside teaching encounters: a video ethnographic study.

CONTEXT: Feedback associated with teaching activities is often synonymous with reflection on action, which comprises the evaluative assessment of performance out of its original context. Feedback in action (as correction during clinical encounters) is an underexplored, complementary resource facilitating students' understanding and learning. OBJECTIVES: The purpose of this study was to explore the interactional patterns and correction modalities utilised in feedback sequences between doctors and students within general practice-based bedside teaching encounters (BTEs). METHODS: A qualitative video ethnographic approach was used. Participants were recorded in their natural settings to allow interactional practices to be contextually explored. We examined 12 BTEs recorded across four general practices and involving 12 patients, four general practitioners and four medical students (209 minutes and 20 seconds of data) taken from a larger corpus. Data analysis was facilitated by Transana video analysis software and informed by previous conversation analysis research in ordinary conversation, classrooms and health care settings. RESULTS: A range of correction strategies across a spectrum of underlying explicitness were identified. Correction strategies classified at extreme poles of this scale (high or low explicitness) were believed to be less interactionally effective. For example, those using abrupt closing of topics (high explicitness) or interactional ambiguity (low explicitness) were thought to be less effective than embedded correction strategies that enabled the student to reach the correct answer with support. CONCLUSIONS: We believe that educators who are explicitly taught linguistic strategies for how to manage feedback in BTEs might manage learning more effectively. For example, clinicians might maximise learning moments during BTEs by avoiding abrupt or ambiguous feedback practices. Embedded correction strategies can enhance student participation by guiding students towards the correct answer. Clinician corrections can sensitively manage student face-saving by minimising the exposure of student error to patients. Furthermore, we believe that the effective practices highlighted by our analysis might facilitate successful transformation of feedback in action into feedback for action.