Is Solicitation of Problem Presentations Always Normative? How Chinese Patients Get to Present Their Reasons for Medical Visits.

Research based on recordings made across numerous specialties and geographical locations has characterized doctors' solicitations of patients' reasons for the visit as normative. However, in our dataset of 132 audio-recordings of consultations in Chinese primary and secondary care, it was as common for patients to self-initiate giving the reason for their visit as it was for doctors to solicit these (n = 65 vs. n = 67 respectively). Based on a conversation analytic examination of our dataset, we show that doctors do not treat patient-initiated problem presentations as deviant. Whilst there are some contextual contingencies (related, for example, to the queuing-system) that might account for this novel finding, these are only partly explanatory. Instead, we argue that, relative to Western contexts, the participants in our data treat the medical consultation as akin to a service-encounter in which patients are entitled to ask for what they want. Implications for understanding medical openings and health outcomes are discussed.

Generating the perception of choice: the remarkable malleability of option-listing.

The normative view that patients should be offered more choice both within and beyond the UK's National Health Service (NHS) has been increasingly endorsed. However, there is very little research on whether - and how - this is enacted in practice. Based on 223 recordings of neurology outpatient consultations and participants' subsequent self-reports, this article shows that 'option-listing' is a key practice for generating the perception of choice. The evidence is two-fold: first, we show that neurologists and patients overwhelmingly reported that choice was offered in those consultations where option-listing was used; second, we demonstrate how option-listing can be seen, in the interaction itself, to create a moment of choice for the patient. Surprisingly, however, we found that even when the patient resisted making the choice or the neurologist adapted the practice of option-listing in ways that sought acceptance of the neurologist's own recommendation, participants still agreed that a choice had been offered. There was only one exception: despite the use of option-listing, the patient reported having no choice, whereas the neurologist reported having offered a choice. We explore this deviant case in order to shed light on the limits of option-listing as a mechanism for generating the perception of choice.

Deferring the Decision Point: Treatment Assertions in Neurology Outpatient Consultations.

Recommendations can be implied by asserting some generalisation about a treatment's benefit without overtly directing the patient to take it. Focusing on a collection of assertions in UK neurology consultations, this paper shows that these are overwhelmingly receipted as "merely" doing informing and argues that this is made possible by their ambiguous design: their relatively depersonalised formats convey that the neurologist is simply telling the patient what's available, but the link made between the treatment and the patient's condition implies that it will be of benefit. Thus, assertions, while stopping short of telling the patient what to do, are hearable as recommendation relevant. This delicates balance leaves it up to the patient to respond either to the implied or on-record action (recommending vs. informing). When treated as "merely" doing informing, assertions defer the decision point until the neurologist has done something more. Three main interactional functions of this are identified as follows: (i) indicating the existence of a solution to a concern, without making a decision relevant next; (ii) orienting to the patient's right to choose; and (iii) making "cautious" recommendations.

Treatment Recommendations as Actions.

From the earliest studies of doctor-patient interaction (Byrne & Long, 1976), it has been recognized that treatment recommendations may be expressed in more or less authoritative ways, based on their design and delivery. There are clear differences between I'm going to start you on X and We can give you X to try and Would you like me to give you X? Yet little is known about this variation, its contexts, or its consequences. In this paper, we develop a basic taxonomy of treatment recommendations in primary care as a first step toward a more comprehensive investigation. We take as our point of departure the observation that treatment recommendations such as those above represent not only different formulations but also different social actions. We distinguish five main treatment recommendation actions: pronouncements, suggestions, proposals, offers, and assertions. We ask: what are the main dimensions on which these recommendations vary and to what end? And what sorts of factors shape a clinician's use of one action type over another with respect to recommending a medication in the primary care context?

Closing the Deal: A Cross-Cultural Comparison of Treatment Resistance.

This study investigates patient resistance to doctors' treatment recommendations in a cross-national comparison of primary care. Through this lens, we explore English and American patients' enacted priorities, expectations, and assumptions about treating routine illnesses with prescription versus over-the-counter medications. We perform a detailed analysis of 304 (American) and 393 (English) naturally occurring treatment discussions and conclude that American and English patients tend to use treatment resistance in different prescribing contexts to pursue different ends. While American patients are most likely to resist recommendations for non-prescription treatment and display an expectation for prescription treatment in these interactions, English patients show a high level of resistance to recommendations for all types of treatment and display an expectation of cautious prescribing. These behavioral trends reflect broader structural forces unique to each national context and ultimately maintain distinct cultural norms of good-practice prescribing.

Articulating reproductive justice through reparative justice: case studies of abortion in Great Britain and South Africa.

Public health and rights-based approaches to abortion advocacy are well established. Feminists are, however, increasingly using a broader framework of 'reproductive justice', which considers the intersecting conditions that serve to enhance or hinder women's reproductive freedoms, including their capacities to decide about the outcome of their pregnancies. Nonetheless, reproductive justice approaches to abortion are, conceptually, relatively under-developed. We introduce a reparative justice approach as a method of further articulating the concept of reproductive justice. We first explain how this approach can be used to conceptualise safe, accessible and supportive abortion as a key element of reproductive justice in relation to the injustice of unwanted or unsupportable pregnancies. Using Ernesto Verdeja's critical theory of reparative justice and case studies of two countries (South Africa and Great Britain) where abortion is legal, we show how such an approach enables an analysis of reproductive justice within the specificities of particular contexts. We argue that both the rights-based legal framework adopted in South Africa and the medicalised approach of British law have, in practice, limited reparative justice in these contexts. We discuss the implications of reparative justice for abortion advocacy.

Patient advocacy and patient centredness in participant recruitment to randomized-controlled trials: implications for informed consent.

CONTEXT: With the routinization of evidence-based medicine and of the randomized-controlled trial (RCT), more patients are becoming 'sites of evidence production' yet, little is known about how they are recruited as participants; there is some evidence that 'substantively valid consent' is difficult to achieve. OBJECTIVE: To explore the views and experiences of nurses recruiting patients to randomized-controlled trials and to examine the extent to which their recruitment practices were patient-centred and patient empowering. DESIGN: Semi-structured in-depth interviews; audio recording of recruitment appointments; thematic interactional analysis (drawing on discourse and conversation analysis). SETTING AND PARTICIPANTS: Nurses recruiting patients to five publicly funded RCTs and patients consenting to the recording of their recruitment sessions. MAIN OUTCOME MEASURES: The views of recruiting nurses about their recruitment role; the extent to which nurse-patient interactions were patient-centred; the nature of the nurses' interactional strategies and the nature and extent of patient participation in the discussion. RESULTS: The nurses had a keen sense of themselves as clinicians and patient advocates and their perceptions of the trial and its interventions were inextricably linked to those of the patients. However, many of their recruitment practices made it difficult for patients to play an active and informed part in the discussion about trial participation, raising questions over the quality of consent decisions. CONCLUSION: Nurses working in patient recruitment to RCTs need to reconcile two different worlds with different demands and ethics. Evidence production, a central task in evidence-based medicine, poses a challenge to patient-centred practice and more research and relevant training are needed.

Initiating decision-making in neurology consultations: 'recommending' versus 'option-listing' and the implications for medical authority.

This article compares two practices for initiating treatment decision-making, evident in audio-recorded consultations between a neurologist and 13 patients in two hospital clinics in the UK. We call these 'recommending' and 'option-listing'. The former entails making a proposal to do something; the latter entails the construction of a list of options. Using conversation analysis (CA), we illustrate each, showing that the distinction between these two practices matters to participants. Our analysis centres on two distinctions between the practices: epistemic differences and differences in the slots each creates for the patient's response. Considering the implications of our findings for understanding medical authority, we argue that option-listing - relative to recommending - is a practice whereby clinicians work to relinquish a little of their authority. This article contributes, then, to a growing body of CA work that offers a more nuanced, tempered account of medical authority than is typically portrayed in the sociological literature. We argue that future CA studies should map out the range of ways - in addition to recommending - in which treatment decision-making is initiated by clinicians. This will allow for further evidence-based contributions to debates on the related concepts of patient participation, choice, shared decision-making and medical authority.

Offering patients choices: a pilot study of interactions in the seizure clinic.

Using conversation analysis (CA), we studied conversations between one United Kingdom-based epilepsy specialist and 13 patients with seizures in whom there was uncertainty about the diagnosis and for whom different treatment and investigational options were being considered. In line with recent communication guidance, the specialist offered some form of choice to all patients: in eight cases, a course of action was proposed, to be accepted or rejected, and in the remaining five, a "menu" of options was offered. Even when presenting a menu, the specialist sometimes conveyed his own preferences in how he described the options, and in some cases the menu was used for reasons other than offering choice (e.g., to address patient resistance). Close linguistic and interactional analysis of clinical encounters can show why doctors may feel they are offering choices when patients report that the decision was clinician dominated.

When do patients exercise their right to refuse treatment? A conversation analytic study of decision-making trajectories in UK neurology outpatient consultations.

Using conversation analysis, this paper investigates when patients exercise their right to refuse treatment in neurology outpatient consultations recorded in the UK's National Health Service in 2012 (n = 224). NHS patients have a right to refuse treatment. However, there are good reasons to suppose that this may be difficult to exercise in practice. We know that clinicians tend to pursue acceptance if it's not forthcoming and those studies that have tracked decision-making trajectories through to their outcomes have shown that clinicians typically convert resistance to acceptance. By contrast, I show that, in 35/40 (87.5 %) cases in which patients sought to refuse treatments made available by a neurologist, they left without a prescription or referral. This paper seeks to explain this apparently anomalous finding. Starting with an example of what I expected to find - a 'duel' that ends with the neurologist persuading the patient to accept treatment - I show that this is, in fact, the exception. By contrast, most of the (attempted) refusals are collaborative, occurring after the neurologist has initiated decision-making in a way that designedly foregrounds the patients' views as the basis for deciding. I show also that, having done so, the neurologists typically continue to treat the decision as subject to the patient's preferences. Thus, the trajectories in my collection - despite including attempts to refuse treatment - do not typically become duels. Rather, patients are refusing treatment in a sequential context that facilitates making their own decision.

Using qualitative research methods to improve recruitment to randomized controlled trials: the Quartet study.

OBJECTIVE: Randomized controlled trials (RCTs) are considered the optimum method for evaluating health care interventions, yet many fail to recruit sufficient participants in a timely manner. The ProtecT (Prostate testing for cancer and Treatment) study employed qualitative research methods as part of a complex intervention to improve recruitment to the RCT. The Quartet (Qualitative research to improve recruitment to trials) study was set up to evalute whether the ProtecT study's success in increasing randomization rates could be replicated in other trials experiencing recruitment difficulties. This paper reports on the issues that emerged from the attempts to apply qualitative research methods to improve recruitment rates in RCTs collaborating with the Quartet team. METHODS: The methods used were: investigation of RCT documents; semi-structured interviews and focus groups with RCT staff; audio-recording of recruitment appointments; and individual and group feedback sessions for RCT staff. Data were analysed using content and thematic analysis. RESULTS: Barriers arose when we attempted to establish collaborations with RCTs. Difficulties were encountered in securing the commitment of all relevant staff because of poor communication between lead investigators and other staff as well as RCT staff's concerns about having recruitment appointments audio-recorded. Recruitment processes were often more complex than anticipated. Governance procedures took considerable time and resources, limiting the time available for data collection and implementation of the intervention before recruitment closure. CONCLUSION: Straightforward replication of the ProtecT complex intervention was more complicated than expected. However, the study has increased understanding of RCT recruitment and identified ways to overcome barriers to collaboration. Such research is more easily undertaken in the feasibility stage of an RCT, and greater success will be achieved if the research is integrated into the everyday conduct of RCTs.

Following the patient's orders? Recommending vs. offering choice in neurology outpatient consultations.

The UK's Royal College of Surgeons (2016) has argued that health professionals must replace a 'paternalistic' approach to consent with 'informed choice'. We engage with these guidelines through analysis of neurology consultations in two UK-based neuroscience centres, where informed choice has been advocated for over a decade. Based on 223 recorded consultations and related questionnaire data (collected in 2012), we used conversation analysis (CA) to identify two practices for offering choice: patient view elicitors (PVEs) and option-lists. This paper reports further, mixed-methods analyses, combining CA with statistical techniques to compare the 'choice' practices with recommendations. Recommendations were overwhelmingly more common. There was little evidence that patient demographics determined whether choice was offered. Instead, decisional practices were associated with a range of clinical considerations. There was also evidence that individual neurologists tended to have a 'style', making it partly a matter of chance which decisional practice(s) patients encountered. This variability matters for the perception of choice: neurologists and patients were more likely to agree a choice had been offered if a PVE or option-list was used. It also matters for the outcome of the decision-making process: while recommendations nearly always ended in agreement to undertake the proffered course of action, option-lists and PVEs did so only about two-thirds of the time. While the direction of causality is unknown, this may indicate that patients are better enabled to refuse things they don't want when neurologists avoid recommending. We argue that our findings imply that neurologists tend to view choice as risky - in that the patient might make the 'wrong' choice - but that the inter-individual variation indicates that greater use of the more participatory practices is possible.

A review identifies and classifies reasons for ordering diagnostic tests.

OBJECTIVE: To consider the reasons and context for test ordering by doctors when faced with an undiagnosed complaint in primary or secondary care. STUDY DESIGN AND SETTING: We reviewed any study of any design that discussed factors that may affect a doctor's decision to order a test. Articles were located through searches of electronic databases, authors' files on diagnostic methodology, and reference lists of relevant studies. We extracted data on: study design, type of analysis, setting, topic area, and any factors reported to influence test ordering. RESULTS: We included 37 studies. We carried out a thematic analysis to synthesize data. Five key groupings arose from this process: diagnostic factors, therapeutic and prognostic factors, patient-related factors, doctor-related factors, and policy and organization-related factors. To illustrate how the various factors identified may influence test ordering we considered the symptom low back pain and the diagnosis multiple sclerosis as examples. CONCLUSIONS: A wide variety of factors influence a doctor's decision to order a test. These are integral to understanding diagnosis in clinical practice. Traditional diagnostic accuracy studies should be supplemented with research into the broader context in which doctors perform their work.

Do patients want choice? An observational study of neurology consultations.

OBJECTIVES: To determine how often patients are given choice in neurology outpatient consultations and whether choice is associated with greater patient satisfaction. METHODS: Prospective study in outpatient clinics in two United Kingdom centres. Interactions between 14 neurologists and 223 patients were studied. Participating doctors and patients completed post-appointment questionnaires asking whether choice had been offered/perceived. Patients completed the Medical Interview Satisfaction Scale 21 (MISS-21). RESULTS: Choice was reported after most encounters (patients 71.8%, neurologists 67.9%). Patients and Neurologists failed to agree about whether choice was offered after 32% of consultations. Choice was not associated with increased patient satisfaction. In fact, satisfaction was greater when no choice had been offered (p=0.05). Satisfaction scores were also greater when doctors were more certain about the diagnosis and when symptoms were considered explained by a medical condition (p≤0.001). CONCLUSIONS: Choice featured in the majority of clinical interactions but clinicians and patients often disagreed whether this was the case. Choice was not associated with greater patient satisfaction. PRACTICE IMPLICATIONS: Clinicians need to be very explicit if they want patients to know that they are being given choices. Choice is not necessarily valued by patients in all clinical interactions.

Clear obstacles and hidden challenges: understanding recruiter perspectives in six pragmatic randomised controlled trials.

BACKGROUND: Recruitment of sufficient participants in an efficient manner is still widely acknowledged to be a major challenge to the mounting and completion of randomised controlled trials (RCTs). Few recruitment interventions have involved staff undertaking recruitment. This study aimed i) to understand the recruitment process from the perspective of recruiters actively recruiting RCT participants in six pragmatic RCTs, and ii) to identify opportunities for interventions to improve recruitment. METHODS: Interviews were undertaken with 72 individuals (32 doctors or RCT Chief investigators (CIs); 40 nurses/other health professionals) who were actively recruiting participants in six RCTs to explore their experiences of recruitment. The RCTs varied in scale, duration, and clinical contexts. Interviews were fully transcribed and analysed using qualitative content and thematic analytic methods derived from grounded theory. For this analysis, data were systematically extracted from each RCT and synthesised across all six RCTs to produce a detailed and nuanced understanding of the recruitment process from the perspectives of the recruiters. RESULTS: Recruiters readily identified organisational difficulties, fewer than expected eligible patients, and patients' treatment preferences as the key barriers to recruitment. As they described their experiences of recruitment, several previously hidden issues related to their roles as researchers and clinicians emerged, imbued with discomfort and emotion. The synthesis across the RCTs showed that doctors were uncomfortable about aspects of patient eligibility and the effectiveness of interventions, whereas nurses were anxious about approaching potential RCT participants and conflicts between the research and their clinical responsibilities. Recruiters seemed unaware that their views contributed to recruitment difficulties. Their views were not known to RCT CIs. Training and support needs were identified for both groups of staff. CONCLUSIONS: The synthesis showed that recruitment to these RCTs was a complex and fragile process. Clear obstacles were identified but hidden challenges related to recruiters' roles undermined recruitment, unbeknown to RCT CIs. Qualitative research can elicit and identify the hidden challenges. Training and support are then needed for recruiters to become more comfortable with the design and principles of RCTs, so that they can engage more openly with potentially eligible participants and create a more resilient recruitment process.

The intellectual challenges and emotional consequences of equipoise contributed to the fragility of recruitment in six randomized controlled trials.

OBJECTIVE: The aim of the study was to investigate how doctors considered and experienced the concept of equipoise while recruiting patients to randomized controlled trials (RCTs). STUDY DESIGN AND SETTING: In-depth interviews with 32 doctors in six publicly funded pragmatic RCTs explored their perceptions of equipoise as they undertook RCT recruitment. The RCTs varied in size, duration, type of complex intervention, and clinical specialties. Interview data were analyzed using qualitative content and thematic analytical methods derived from grounded theory and synthesized across six RCTs. RESULTS: All six RCTs suffered from poor recruitment. Doctors wanted to gather robust evidence but experienced considerable discomfort and emotion in relation to their clinical instincts and concerns about patient eligibility and safety. Although they relied on a sense of community equipoise to justify participation, most acknowledged having "hunches" about particular treatments and patients, some of which undermined recruitment. Surgeons experienced these issues most intensely. Training and support promoted greater confidence in equipoise and improved engagement and recruitment. CONCLUSION: Recruitment to RCTs is a fragile process and difficult for doctors intellectually and emotionally. Training and support can enable most doctors to become comfortable with key RCT concepts including equipoise, uncertainty, patient eligibility, and randomization, promoting a more resilient recruitment process in partnership with patients.

Using electronic patient records in practice: a focused review of the evidence of risks to the clinical interaction.

Electronic patient records (EPRs) are increasingly being viewed as key to high quality chronic disease management, and have been advocated for epilepsy care. Whether EPRs can really deliver on their promise, however, remains a matter of debate. In this focused review, I highlight one set of risks associated with EPR use: risks to the interaction between health professional and patient. This review summarises a small body of evidence derived from studies that examined - in fine-grained detail - recordings of real consultations. These show that EPRs are often used in ways that prioritise the demands of the system over the needs of the patient. However, they also demonstrate that health professionals sometimes integrate EPRs in ways that enhance the clinical encounter. I argue that we not only need more of this kind of interaction-based research - as opposed to focusing on the single EPR user - but that the findings from these previous studies need to be acted upon. They indicate a need both for the design of EPRs and the training of EPR users to be sensitive to the impact of EPR use on the interaction between health professional and patient.

A review of reporting of participant recruitment and retention in RCTs in six major journals.

BACKGROUND: Poor recruitment and retention of participants in randomised controlled trials (RCTs) is problematic but common. Clear and detailed reporting of participant flow is essential to assess the generalisability and comparability of RCTs. Despite improved reporting since the implementation of the CONSORT statement, important problems remain. This paper aims: (i) to update and extend previous reviews evaluating reporting of participant recruitment and retention in RCTs; (ii) to quantify the level of participation throughout RCTs. METHODS: We reviewed all reports of RCTs of health care interventions and/or processes with individual randomisation, published July-December 2004 in six major journals. Short, secondary or interim reports, and Phase I/II trials were excluded. Data recorded were: general RCT details; inclusion of flow diagram; participant flow throughout trial; reasons for non-participation/withdrawal; target sample sizes. RESULTS: 133 reports were reviewed. Overall, 79% included a flow diagram, but over a third were incomplete. The majority reported the flow of participants at each stage of the trial after randomisation. However, 40% failed to report the numbers assessed for eligibility. Percentages of participants retained at each stage were high: for example, 90% of eligible individuals were randomised, and 93% of those randomised were outcome assessed. On average, trials met their sample size targets. However, there were some substantial shortfalls: for example 21% of trials reporting a sample size calculation failed to achieve adequate numbers at randomisation, and 48% at outcome assessment. Reporting of losses to follow up was variable and difficult to interpret. CONCLUSION: The majority of RCTs reported the flow of participants well after randomisation, although only two-thirds included a complete flow chart and there was great variability over the definition of "lost to follow up". Reporting of participant eligibility was poor, making assessments of recruitment practice and external validity difficult. Reporting of participant flow throughout RCTs could be improved by small changes to the CONSORT chart.

Qualitative research to improve RCT recruitment: issues arising in establishing research collaborations.

INTRODUCTION: Strategies to improve recruitment to RCTs (randomised controlled trials) are limited. The ProtecT (Prostate testing for cancer and Treatment) study successfully developed a complex intervention based on qualitative research methods to increase recruitment rates. The Quartet study (Qualitative Research to Improve Recruitment to RCTs) was established to evaluate whether the ProtecT qualitative methods could be transferred into other RCTs. This paper reports on the barriers and facilitators in setting up these collaborations. METHODS: The Quartet study collaborated with five RCTs. Qualitative methods used were: interviews and focus groups with RCT staff; audio-recording recruitment interactions; and feedback sessions for RCT staff based on qualitative findings. Data were audio-recorded, transcribed and analysed using content and thematic analyses. Issues arising during establishment of collaborations were recorded and analysed. RESULTS: Establishing collaborations proved challenging and not always surmountable. Difficulties were encountered in gaining agreement of RCT staff to participate because of central RCT staff's lack of authority over recruitment staff, poor communication within RCTs and recruiters' reluctance to have their practice scrutinised. The complexity of the recruitment process also hindered translation of ProtecT methods. Although Quartet enabled significant recruitment issues to surface, the bureaucratic tasks involved in securing governance approval delayed onset of collaborations, reducing the time to address issues and evaluate Quartet's impact. DISCUSSION: The Quartet study established collaborations with a range of RCTs and gained valuable insights for future collaborations between qualitative researchers and RCTs. Qualitative research methods need to be included at the feasibility stage of a RCT or fully integrated into the RCT, as in the ProtecT study, with routine audio-recording for monitoring and training purposes. Quartet-like collaborations could then be established without delay, and recruitment processes of RCTs could become transparent, monitored and improved.