How Do Physicians Frame Medical Information in Talks With Their Patients? An Inductive Microanalysis.

During medical consultations, physicians need to share a substantial amount of information with their patients. How this information is framed can be crucial for patient understanding and outcomes, but little is known about the details of how physicians frame information in practice. Using an inductive microanalysis approach in the study of videotaped medical interactions, we aimed to identify the information frames (i.e., higher-level ways of organizing and structuring information to reach a particular purpose) and the information-framing devices (i.e., any dialogic mechanism used to present information in a particular way that shapes how the patient might perceive and interpret it) physicians use spontaneously and intuitively while sharing information with their patients. We identified 66 different information-framing devices acting within nine information frames conveying: (1) Do we agree that we share this knowledge?, (2) I don't like where I (or where you are) am going with this, (3) This may be tricky to understand, (4) You may need to think, (5) This is important, (6) This is not important, (7) This comes from me as a doctor, (8) This comes from me as a person, and (9) This is directed to you as a unique person. The kaleidoscope of information-framing devices described in this study reveals the near impossibility for neutrality and objectivity in the information-sharing practice of medical care. It also represents an inductively derived starting point for further research into aspects of physicians' information-sharing praxis.

Code-switching in multilinguals with dementia: patterns across speech contexts.

The study investigates code-switching by multilingual persons with dementia in two different speech contexts, picture naming tests and spontaneous conversation. It combines a psycholinguistic perspective on cognitive and linguistic skills with a qualitative conversation analytic approach to understanding the functions and appropriateness of code-switching in social interaction. The analysis shows that code-switching is used as a resource for compensating for word-retrieval problems in both the naming tests and in word search sequences in conversation. Furthermore, it serves to demarcate meta-communicative parentheses in which the participants comment on their process of word retrieval or express frustration about processing problems. Code-switching is generally treated as appropriate and relevant by the participants. In most instances, the speakers switch to a language known by the interlocutor. Only a few instances are treated as inappropriate by not being understandable to the interlocutor or by not adapting to the established language of the conversation. The patterns of code-switching are discussed considering typical symptoms of cognitive decline associated with dementia. Only very few instances may be interpreted as caused by a lack of awareness of the interlocutor's language background (associated with reduced episodic memory) or a lack of inhibition. Code-switching thereby presents itself primarily as a communicative resource for handling and overcoming another dementia-related symptom, namely anomia.

Eliciting patient preferences in shared decision-making (SDM): Comparing conversation analysis and SDM measurements.

OBJECTIVE: To explore how physicians bring up patient preferences, and how it aligns with assessments of shared decision-making. METHODS: Qualitative conversation analysis of physicians formulating hypotheses about the patient's treatment preference was compared with quantitative scores on SDM and 'patient preferences' using OPTION(5) and MAPPIN'SDM. RESULTS: Physicians occasionally formulate hypotheses about patients' preferences and then present a treatment option on the basis of that ("if you think X+we can do Y"). This practice may promote SDM in that the decisions are treated as contingent on patient preferences. However, the way these hypotheses are formulated, simultaneously constrains the patient's freedom of choice and exerts a pressure to accept the physician's recommendation. These opposing effects may in part explain cases where different assessment instruments yield large variations in SDM measures. CONCLUSION: Eliciting patient preferences is a complex phenomenon that can be difficult to reduce into an accurate number. Detailed analysis can shed light on how patient preferences are elicited, and its consequences for patient involvement. Comparing CA and SDM measurements can contribute to specifying communicative actions that SDM scores are based on. PRACTICE IMPLICATIONS: Our findings have implications for SDM communication skills training and further development of SDM measurements.

Patient involvement and language barriers: Problems of agreement or understanding?

OBJECTIVE: This study aims to explicate efforts for realizing patient-centeredness (PCC) and involvement (SDM) in a difficult decision-making situation. It investigates what communicative strategies a physician used and the immediate, observable consequences for patient participation. METHODS: From a corpus of videotaped hospital encounters, one case in which the physician and patient used Norwegian as lingua franca was selected for analysis using conversation analysis (CA). Secondary data were measures of PCC and SDM. RESULTS: Though the physician did extensive interactional work to secure the patient's understanding and acceptance of a treatment recommendation, his persistent attempts did not succeed in generating the patient's participation. In ratings of PCC and SDM, this case scored well above average. CONCLUSION: Despite the fact that this encounter displays some of the 'best actual practice' of PCC and SDM within the corpus, our analysis of the interaction shows why the strategies were insufficient in the context of a language barrier and possible disagreement. PRACTICE IMPLICATIONS: When facing problems of understanding, agreement and participation in treatment decision-making, relatively good patient centered skills may not suffice. Knowledge about the interactional realization of key activities is needed for developing training targeted at overcoming such challenges.

Negotiating treatment preferences: Physicians' formulations of patients' stance.

Eliciting patients' values and treatment preferences is an essential element in models of shared decision making, yet few studies have investigated the interactional realizations of how physicians do this in authentic encounters. Drawing on video-recorded encounters from Norwegian secondary care, the present study uses the fine-grained empirical methodology of conversation analysis (CA) to identify one conversational practice physicians use, namely, formulations of patients' stance, in which physicians summarize or paraphrase their understanding of the patient's stance towards treatment. The purpose of this study is twofold: (1) to explore what objectives formulations of patients' stance achieve while negotiating treatment and (2) to discuss these objectives in relation to core requirements in shared decision making. Our analysis demonstrates that formulating the patient's stance is a practice physicians use in order to elicit, check, and establish patients' attitudes towards treatment. This practice is in line with general recommendations for making shared decisions, such as exploring and checking patients' preferences and values. However, the formulations may function as a device for doing more than merely checking and establishing common ground and bringing up patients' preferences and views: Accompanied by subtle deprecating expressions, they work to delegitimize the patients' stances and indirectly convey the physicians' opposing stance. Once established, these positions can be used as a basis for challenging and potentially altering the patient's attitude towards the decision, thereby making it more congruent with the physician's view. Therefore, in addition to bringing up patients' views towards treatment, we argue that physicians may use formulations of patients' stance as a resource for directing the patient towards decisions that are congruent with the physician's stance in situations with potential disagreement, whilst (ostensibly) avoiding a more authoritarian or paternalistic approach.