Communication in Medical Care: Interaction Between Primary Care Physicians and Patients

Half-title......Page 3
Series-title......Page 4
Title......Page 5
Copyright......Page 6
Contents......Page 7
Figures......Page 9
Tables......Page 10
Contributors......Page 11
Foreword......Page 13
Temporal and sequential relationships......Page 16
Aspects of speech delivery, including aspects of intonation......Page 18
Other markings......Page 20
1 Introduction: Analyzing interaction between doctors and patients in primary care encounters......Page 23
Process analysis......Page 24
Microanalysis......Page 26
Taking stock......Page 28
(1) Conversation analysis: a brief introduction......Page 31
The primary care interview: levels of analysis......Page 35
Overall structural organization......Page 36
Sequence organization......Page 37
Turn design......Page 39
Conclusion......Page 41
2
Soliciting patients’ presenting concerns......Page 44
Data......Page 46
Question formats designed to solicit new concerns......Page 47
How are you feeling?......Page 51
Quantitative results for follow-up-concern question formats......Page 57
Question formats designed to index chronic-routine visits......Page 58
Question formats that do not index patients’ institutionally
relevant concerns......Page 61
Question formats that are inappropriately fitted
to patients’ concerns......Page 63
Discussion......Page 67
Introduction......Page 70
Presenting a concern: initial considerations......Page 72
Routine acute problems......Page 73
Recurrent problems......Page 74
Unknown medical problems......Page 76
Accounting for the visit: the problem of legitimate doctorability......Page 79
Practices for justifying medical visits......Page 87
Making diagnostic claims......Page 88
Invoking third parties......Page 93
Troubles resistance......Page 96
Troubles resistance in “routine acute” medical problems......Page 98
Troubles resistance in “unknown” medical problems......Page 100
Concluding remarks......Page 105
Introduction......Page 108
The “patients’ problem”......Page 110
Teach us to care and not to care: the “balance of involvement and detachment”......Page 112
Establishing the “reason for visit” vs. “taking a history”......Page 115
“At first I thought ‘X’”......Page 119
A “sequence of noticings”......Page 122
Doing things with stories: uses of the narratives......Page 124
Conclusion: a social epistemics of sensation......Page 132
Problem-discovery narratives as patients’ models in situ......Page 134
Clinical implications: working at being a reasonable patient......Page 135
Introduction......Page 137
Design of patients’ explanations for health problems......Page 139
Overt explanations......Page 140
Tacit explanations......Page 142
Explanation design and placement......Page 145
Explanations that strongly compel doctors’ confirming or disconfirming assessments......Page 148
Doctors’ immediate disconfirming assessments......Page 150
Doctors’ immediate confirming assessments......Page 152
Explanation–query sequences......Page 154
Query focuses on the patient’s symptom, no assessment occurs......Page 157
Query focuses on the causal factor, no assessment occurs......Page 159
Query focuses on the patient’s symptom, assessment occurs after a delay......Page 162
Query focuses on evidence the patient provides, assessment occurs after a delay......Page 165
Conclusion......Page 168
Introduction......Page 173
The data......Page 175
Question design: some basic preliminaries......Page 176
Medical questioning sets agendas......Page 177
Medical questioning embodies presuppositions......Page 181
Medical questioning can “prefer” particular responses......Page 182
Two principles of routine medical questioning......Page 185
The principle of optimization......Page 186
The principle of recipient design......Page 188
Medical history-taking: constructing routines and contingencies......Page 190
Handling contingencies......Page 193
Optimization and recipient design: clashes and resolutions......Page 196
“Alcohol use?”: an excursion into lifestyle......Page 200
Discussion......Page 204
Introduction......Page 207
Constituting the body as an object......Page 211
Configuring the site......Page 217
Revealing symptoms......Page 227
Discussion: patient participation and professional assessment......Page 230
Introduction......Page 236
Earlier research on diagnosis......Page 237
Data for the study......Page 238
How the doctors tell the patient about the diagnosis......Page 239
Three types of diagnostic utterance......Page 240
Presence of evidence in plain assertions......Page 244
Departures from the default pattern......Page 246
Problems arising from extended inferential distance......Page 247
Problems arising from challenges to medical expertise......Page 250
The patients’ responses to the doctors’ diagnostic utterances......Page 255
When do the patients talk after hearing the diagnosis?......Page 256
Patient displaying agreement......Page 260
Patients resisting the doctors’ diagnosis......Page 261
Responses to diagnosis: a summary......Page 266
Conclusion......Page 268
9
On diagnostic rationality: bad news, good
news, and the symptom residue......Page 270
Diagnostic news deliveries in primary care......Page 272
Asymmetries between good and bad news: minor conditions......Page 274
Cardiovascular good news......Page 278
Cancer bad news......Page 282
Comparing good and bad news in primary care......Page 288
Good news, indeterminacy, and uncertainty: the problem
of symptom residue......Page 293
Conclusion......Page 298
10
Treatment decisions: negotiations between
doctors and parents in acute care encounters......Page 301
Patient participation in health care......Page 302
Responses to diagnosis deliveries and treatment recommendations......Page 303
Withholding acceptance as passive resistance......Page 305
Active resistance......Page 310
The format of treatment recommendation......Page 322
Parent responses to alternative treatment
recommendation formats......Page 325
Treatment recommendation formats: implications
for health care practitioners......Page 331
Discussion......Page 332
Introduction......Page 335
The computer system......Page 337
Communicating prescription-related information that corresponds
to details entered into the computer fields......Page 340
Communicating prescription-related information which does not
correspond to details entered into the computer fields......Page 345
Patients’ responses......Page 350
The patients’ bodily movements as they ask questions......Page 354
The patients’ bodily movements during the doctors’ responses......Page 355
Discussion......Page 357
Earlier research......Page 362
Data......Page 364
Questions that are asked subsequent to a formulation
of a medical problem......Page 365
Questions that are asked further away from the
formulation of the medical problem......Page 367
Types of no-problem answer......Page 369
Reception of no-problem answers......Page 372
Exits from the discussions on a lifestyle issue in no-problem cases......Page 375
Establishing lifestyle as problematic......Page 377
Overt problem orientation......Page 378
Consolidating an incipient problem orientation......Page 380
Incipient problem orientation that is not consolidated......Page 386
Advice on lifestyle......Page 388
Advice that is sequentially “next” after the history-taking......Page 391
Advice with no preceding interview......Page 393
Invoking the problem orientation through advice......Page 395
Summary and conclusion......Page 398
Introduction......Page 401
Empirical studies of closings in primary care visits......Page 403
Closings in conversation......Page 405
Bounding off and shutting down conversational topics......Page 407
Announcing closure......Page 409
Termination......Page 411
Preclosing......Page 414
Preparing for preclosing......Page 420
Responding to preclosing initiations......Page 423
“By the way ...”......Page 427
Managing termination and producing continuity of care......Page 431
Closing......Page 436
Introduction: after-hours calls as a form of telephone medicine......Page 438
The doctor’s decision about whether to make home visits,
in response to after-hours calls......Page 441
A misalignment between caller and doctor......Page 445
Callers pursue dramatic detailing of patients’ symptoms......Page 447
Caller and doctor display a different assessment of the significance
of certain diagnostic signs or symptoms......Page 454
Callers’ diagnostic hypotheses......Page 459
Conclusion......Page 465
References......Page 467
Subject index......Page 503
Name index......Page 506