Conversation Analysis and Medicine
Summary and Keywords
Beginning with phone calls to an emergency psychiatric hospital and suicide prevention center, the roots of Conversation Analysis (CA) are embedded in systematic analyses of routine problems occurring between ordinary persons facing troubling health challenges, care providers, and the institutions they represent. After more than 50 years of research, CA is now a vibrant and robust mode of scientific investigation that includes close examination of a wide array of medical encounters between patients and their providers. Considerable efforts have been made to overview CA and medicine as a rapidly expanding mode of inquiry and field of research. Across a span of 18 years, we sample from 10 of these efforts to synthesize important priorities and findings emanating from CA investigations of diverse interactional practices and health care institutions. Key topics and issues are raised that provide a unique opportunity to identify and track the development and maturity of CA approaches to medical encounters. Attention is also given to promising new modes of research, and to the potential and challenges of improving medical practices by translating basic and rigorous empirical findings into innovative interventions for medical education. A case is made that increasing reliance on CA research can positively impact training and policies shaping the delivery of humane and quality medical care.
The Ontogenesis of Conversation Analysis, Health, and Medicine
The origin of Conversation Analytic (CA) concerns with health and medical care can be traced to Harvey Sacks’s (cofounder of CA, with Emmanuel Schegloff and Gail Jefferson) recorded and transcribed lectures from fall 1964–spring, 1965 (Jefferson, 1992). At the outset of the first lecture, Sacks provides transcribed data from openings of three telephone conversations between a staff member and callers who have contacted an emergency psychiatric hospital. His first observation is that staff members and callers are talking for the first time. Call-takers are bureaucratic representatives of the hospital, professionals trained to receive and respond to calls for help for persons “in trouble in one way or another” (p. 3). Speaking on behalf of the institution, call-takers respond as staff responsible for providing expert assistance to those in need. Specific details of these troubles, and possibilities for offering assistance, would emerge as these conversations unfolded. If calling for someone else, it is assumed that another’s trouble is the primary reason for the call. In either case, callers reach out in search of information, aid, and support. Apparently, those calling cannot sufficiently manage troubles by themselves. And as Sacks later observed, many calls were made because there was “no one to turn to” (1967), and the corollary, “you want to find out if anybody really does care” (1987).
Throughout these calls, one particular problem and concern for “the hospital” was that numerous callers would not provide their names. Sacks began to investigate how these names were withheld, and “It was in fact on the basis of that question that I began to try to deal in detail with conversations” (p. 3). Closer examination of moments when callers did and did not provide their names, including responses to staff members’ opening utterances (e.g., “Can I help you?” vs. “This is Mr Smith may I help you”), contributed in significant and perhaps unexpected ways to the development of basic “rules of conversational sequence” (Jefferson, 1992). As a backdrop, in his introduction to Sacks’s Lectures on Conversation, Schegloff (1992) describes how Sacks and colleagues (Harold Garfinkel and, at times, Erving Goffman) worked together with the Los Angeles Suicide Prevention Center (SPC). Among many other scholarly interests it was Sacks’s engagement with suicidal persons, and those trained to counsel such individuals, “which provided the proximal source for the focused attention on talk itself—perhaps the most critical step toward the development of conversation analysis” (p. xvi).
Even prior to accessing SPC recordings and transcriptions, Schegloff reports that in 1962–63 he initiated work at the Law and Society Center in Berkeley by “tape recording psychiatric competency and criminal insanity examinations for subsequent analysis” (1963, p. xvii). And there were certainly other, and potentially consequential influences, impacting how the emergence of CA was interwoven with close examinations of naturally occurring medical and health circumstances. For example, Goffman (Sacks’s initial dissertation advisor) conducted early work on mental institutions in Asylums (1961), David Sudnow’s (Sacks’s colleague) dissertation focused on the social processes of death and dying and was eventually published as Passing On (1967), and Garfinkel’s own involvements with SPC provided numerous opportunities for discussions with Sacks about communication and suicide (and a wide variety of other matters revealed in his 1967 Studies in Ethnomethodology, as well as a paper coauthored with Sacks (1970) on how practical actions are organized through formal structures).
Historically, then, the roots of CA are embedded in systematic analyses of routine problems occurring between ordinary persons facing troubling health challenges, care providers, and the institutions they represent. Though more than 50 years have now passed since initial attention was given to psychiatric troubles, and their suicidal manifestations, it is clear that insights into the interactional organization of these encounters contributed in significant ways to the ontogenesis of CA.
Now a vibrant and robust mode of scientific investigation (see Sidnell & Stivers, 2013), CA focuses on a wide array of both ordinary conversations and institutional interactions (e.g., courtroom interrogations and testimony, 9-1-1 emergency calls, medical consultations, psychotherapy sessions). Systematic attention is given to diverse interactions involving health and medical care. In a very real sense, how patients seeking care “turn to others for help,” working to determine if “anyone does really care,” remain primary and consequential concerns for lay and medical professionals alike. Especially during medical encounters, it is critically important to understand how patients raise (and/or avoid raising) often complex problems (mental, emotional, physical, and spiritual). In turn, how (or if) providers address and attempt to resolve patients’ concerns, and their success in so doing, continues to present recurring challenges and unique opportunities for providing quality care.
Considerable efforts have been made to overview CA and medicine as a rapidly expanding mode of inquiry and field of research (e.g., see Drew, Chatwin, & Collins, 2001). Below we sample from 10 of these efforts in order to synthesize important priorities and findings emanating from CA investigations of diverse interactional practices and health care institutions. Key topics and issues are raised about CA approaches to medical encounters. Attention is also given to promising new modes of research, and to the potential and challenges of improving medical practices by translating basic empirical findings into innovative educational interventions. Reliance on CA research can positively impact medical training and policies shaping the delivery of quality medical care.
CA Approaches to Medicine: Depth, Breadth, and Application
One primary indicator of growth in a discipline is repeated and ongoing attempts to review and take stock of current findings, issues, and challenges emanating from scholarly efforts designed to advance a field of inquiry. A selection of 10 such efforts is discussed below, representing a span of 18 years (1997–2015), which collectively provides a unique opportunity to identify and track the increasing maturity of CA approaches to medical encounters. Overviews are provided chronologically to provide a sense of historical development, and thus to preserve unfolding and cumulative attempts to characterize CA’s approaches to medical care.
Following these overviews, a summary is provided (see Table 1) of topics/issues addressed, CA’s contributions to studying medical encounters, and implications for clinical decision making and practice.
CA As a Viable New Method for Investigating Doctor-Patient Communication
With notable and groundbreaking exceptions, such as Heath’s (1986) Body Movement and Speech in Medical Interaction (1986), Peräkylä (1997) describes how previous studies of doctor-patient communication have relied predominantly on “aggregation techniques” that code and count certain behaviors (e.g., positive and supporting talk). Although helpful, these aggregation techniques do not adequately provide in-depth understandings of naturally occurring social interactions between doctors and patients. In contrast, CA can be used “to describe the particular ways in which both parties accomplish their tasks through the sequential organization of interaction” (p. 205), providing richer and more nuanced understandings of medical encounters. An example is provided of how CA can be applied to better understand the delivery and reception of diagnostic news. Distinctions can be made between “straight factual assertions” (e.g., your leg is broken) and “evidence formulating patterns” (e.g., describing observations about the leg in order to provide evidence of a diagnosis). These distinctions illustrate how CA provides grounded insights into “different ways of accomplishing given medical tasks” (p. 207, emphasis original).
Relevance of CA for Medical Research and Education
Eight years following Peräkylä’s (1997) introduction of CA to diverse researchers studying and practicing medicine, Maynard and Heritage (2005) focus directly on how using CA to study the organization of interaction differs in significant ways with methods relying on individuals’ descriptions of social order (e.g., ethnographic coding and reliance on personal anecdotes). Five basic components of CA are described. The first component, utterances as social activities, refers to how “the most banal and familiar conversational utterances are social objects that accomplish actions and activities without necessarily formulating them as such” (p. 429, emphasis original). For example, rather than announcing that a person is greeting a friend, s/he just utters “Hello.” Social actions frequently occur without explanations and are produced as the ordinary features of interactions (e.g., requesting, offering, insulting, joking). The second component, sequencing, highlights how each conversational utterance is shaped by the communication that happens before (i.e., context-shaped) while also influencing the communication that happens after (i.e., context-renewing). The authors discuss a third component of conversation analysis, “interaction is deeply orderly everywhere” (p. 430), to emphasize how interactional details are sites for social order and organization. Actions produced through even silences and laughter (e.g., see Beach & Pricket, 2016), for example, may display how discomfort is being oriented to and managed. The fourth component, grounding analysis in participants’ orientations, elucidates how close attention is drawn to examining the interaction itself—how utterances (and bodily actions) are produced before and after current speakers’ behaviors—to determine what speakers treat as meaningful as actions unfold. By analyzing locally produced, sequentially unfolding talk and bodily actions, the final CA component discusses how analysis proceeds by relying on single cases and collections of moments to “develop claims about systematic structural organization in interaction” (p. 430).
These components are then shown to be relevant not just for studying ordinary, casual conversations but also institutional encounters during medical interviews. An overview is provided of a recently published, 14-chapter edited volume entitled Communication in Medical Care: Interactions between Primary Care Physicians and Patients (Heritage & Maynard, 2006a), which includes various authors’ analyses of diverse aspects of recorded and transcribed medical encounters (e.g., soliciting patients’ concerns, negotiating treatment decisions and recommendations, and closing interviews). From these and related studies, potential applications of CA to medical education include advancing improvements in patient-provider communication through training programs. By incorporating faculty-supervised reviews of recorded student visits, and by relying on empirical findings revealing specific patterns of conduct (e.g., alternative techniques for opening and closing medical encounters), grounded recommendations for improving communication can be offered.
Problems and Prospects across Thirty Years of Medical Research
During this same period of time, Heritage and Maynard (2006b) further develop a compelling case for the importance of CA when examining communication during medical encounters. The case is made that previous research on doctor-patient interaction has mostly utilized either microanalysis or process analysis, the latter involving coding schemes such as the Roter Interactional Analysis System (RIAS). With a broad range of categories (39 in the RIAS system), coding schemes like RIAS have been utilized to study and reveal new and important information about diverse medical encounters, systematically produced findings that are often generalizable. However, because a variety of coding categories and instructions in schemes such as RIAS are overly general, they tend to miss key social actions comprising interactions between doctors and patients.
In contrast, the microanalysis reflected in CA inquiries reveals the moment-by-moment sequential orientations of participants evident within recorded and carefully transcribed discourse comprising medical encounters. Analysts find specific cases in the interaction in which particular types of behavior are demonstrated (e.g., patients providing candidate diagnoses), and these cases can be further validated by building and closely examining larger collections of instances. Yet because microanalysis inevitably relies on analysts’ interpretations when advancing empirical claims, it remains for CA to consistently prove that data selected for presentation are representative, generalizable to larger populations, and replicable. To face these challenges, “an analytical framework is required that is responsive to very granular, individual moments in the physician-patient encounter, but that simultaneously supports coding at a higher level of abstraction sufficient to reach beyond individual cases to generate findings at a statistical evidentiary standard” (p. 362). Ongoing work by CA has developed such a framework by first generating empirical descriptions and explanations for single cases and collections of phenomena, then generating grounded coding categories replete with instructions for reliably identifying selected social actions (see Stivers, 2015). For example, recent CA-based coding research focuses on impacts of breast cancer patients’ question asking on satisfaction with surgeons and care (Venetis, Robinson, & Kearney, 2013); how first-visit cancer patients raise and oncologists respond to fears, uncertainties, and hopes (Beach, Gutzmer, & Dozier, 2015); and ways that primary care physicians set agendas and solicit additional concerns from patients (Robinson & Heritage, 2015; Robinson, Tate, & Heritage, 2016).
To summarize, when understood as a rigorous qualitative methodology, CA’s ability to validate and generalize claims is complemented when integrated with various quantitative analyses (e.g., pre-post surveys and outcome data). In a growing number of studies, “the CA observations introduced into several analyses as coded variables have proved strikingly robust in the multivariate context. This may be less surprising than it seems. The CA variables have been painstakingly validated in the most direct way possible, by examining the unmediated behavior of recipients of the conduct in question. If this conduct has significance on a case-by-case basis, it should survive and enrich the multivariate analysis” (p. 367). With these research protocols, CA can provide a richer understanding of single case and larger collections of interactional moments occurring within, and shaping the quality and outcomes, of an array of routine medical encounters.
An E-Resource for Behavioral and Social Science Researchers
The theoretical underpinnings and methodological commitments of CA are further elaborated in Heritage’s (2009) e-source overview for social and behavioral scientists interested in studying medical encounters. Emphasis is given to why and how “CA begins from the notion that conversational interaction involves ‘doing things with words,’ and that, for example, describing, questioning, agreeing, offering and so on are all examples of social actions that we use words to perform” (p. 2). As with previous discussions of ways CA can compensate for alternative approaches, methods that can tend to gloss specific details of interaction, CA was created to address the fact that even the most inconspicuous social actions are meaningful—in the first instance, in just the ways participants use language and rely on their bodies to accomplish clinical interactions and negotiate meaningful and shared understandings.
Relying on CA, medical encounters can be examined by focusing on one or across any combination of four analytic levels: (a) overall phase structure, (b) sequence organization, (c) turn design, and (d) lexical choice. Analysis of the overall phase structure allows researchers to examine how each component and set of tasks during the medical visit, from openings to closings, are managed by doctors and patients. In contrast, sequence organization involves analyzing the structure of particular segments of interaction between parties. At an even more detailed level, turn-design explicates particular and constituent features of utterances between speakers. Finally, lexical choice reveals how specific words are used in the medical encounters and the relevance of these words, as with a doctor’s use of “we,” to establish medical authority as a bureaucratic representative of medical institutions.
Two routes for using CA to influence clinical outcomes and decisions are described. First,“if we wish to demonstrate the relevance of interaction for medical decision making, data on interactional practices needs to be merged with clinical information, data about health beliefs and attitudes, and clinical decisions. All this implies the creation of coded, quantitative data from individual cases, involving the sacrifice of nuance and detail for the ‘big picture’ features of the interaction which translate across individual cases” (p. 26). When using CA as an empirical basis for subsequent data coding and quantitative analyses, it is crucial to show particular care in the coding process and have specific interactional examples on hand to ensure proper identification and agreement across instances. Second, CA findings can be used for educational interventions targeting skill improvements for care providers. For training and workshops, the specificity and nuance of selected interactional moments can be used to invite medical professionals to work as teams, with CA experts, to both analyze and discuss implications of determining what interactions practices might be more or less useful as techniques for advancing patient-centered care.
Examining Health Communication With CA Methods
Coding issues are also addressed by Robinson (2011), who recognizes that even though CA has become the dominant method for analyzing social interaction, there are numerous benefits to be gained by relying on rigorous CA findings as a basis for generating “big picture” and “big number” results through coding and statistical quantification of results. Mixing methods can be advantageous, since “there has been a social-scientifically pragmatic and symbiotic relationship between CA and traditional coding methods, the former qualitatively bringing validity to the latter, and the latter quantitatively empowering the former” (p. 3). A complementary, mixed methods solution is proposed that makes explicit the inherent limitations of both qualitative and quantitative methods, but also integrates methods in innovative ways to (a) preserve the naturally occurring practices and patterns of social interaction, (b) avoid coding with categories that do not adequately represent the social order, and (c) eliminate discreet codings that are not sensitive to the co-construction of interactional moments and sequential environments.
Transcribed excerpts from patient-provider interactions are relied on to demonstrate how different interactional contexts can alter provider-client communication, how CA-derived interaction trends affect medical outcomes, and how CA research can be practically applied in medical interactions to improve medical outcomes. To achieve these goals, mixed methods approaches can provide an accurate, widespread, and practical foundation for improving medical practice. Three CA studies are explained to support the importance of CA in medical communication studies. For example, Boyd (1998) found that insurance agents were more likely to get a surgical procedure approved by a physician if they opened a phone conversation with a “collegial opening,” including open-ended and friendly conversational patterns, compared with a “bureaucratic opening” that featured specific questions for gathering information (see also Beach, 2009a; Beach & Lockwood, 2003). Heritage, Robinson, Elliot, Beckett, and Wilkes (2007) found that the intervention of having physicians watch a five-minute training CD, based on CA findings, was able to reduce how often patients left the doctor’s office with unmet concerns by 75%. As summarized by Robinson (2011), “CA-derived patterns of interaction are amenable to quantification, are associated with post-interaction medical outcomes, and are translatable to providers for the purpose of health-care intervention” (p. 33).
CA As a Humane Approach to Patient-Provider Interactions
The ability to translate basic research findings into resources for medical education qualifies CA as an evidence-based, systematic approach to discovering best practices for humane patient-provider communication (Gill & Roberts, 2013). Medical CA has tended to focus on analyzing audio and videotaped interactions to discover patterns of social actions. By recognizing roots in early work such as Heath (1986) and Atkinson (1995), however, the essential interplay of both vocal and nonvocal actions in medical encounters is apparent. It is critical to gain access to the importance of gaze, touch, reliance on medical records, and a host of related moments where talk, bodies, and actions weave a complex social web throughout medical interactions.
Equally important is the recognition that CA is inherently an inductive method that does not rely on secondary sources as primary data (e.g., self-report questionnaires, anecdotal information from interviews). Many studies use alternate methodologies focusing too heavily on individuals’ reported experiences, or outcomes not connected to specific interactional practices, rather than making apparent the unique struggles, successes, and complexities of co-constructed interaction involving health and medical care (e.g., see also Beach, 2009a, 2009b; Beach & Anderson, 2003, 2004). In contrast, a direct focus on talk and embodied actions has revealed a bounty of phenomena (e.g., delivering and receiving diagnostic news, negotiating treatment recommendations, offering and resisting advice) that other methods have neglected to notice in any substantive detail.
Conversation analysts agree that in a typical medical encounter, following original research by Byrne and Long (1976), interactions transition through six common phases: opening, problem presentation, history taking and physical examination, diagnosis, treatment recommendation(s), and closing. Beyond these basic goals and phases of interaction, other complexities arise. For example, many patients have a goal of presenting their illness as “doctorable” and justifying their request for their doctor’s time and expertise. At times patients often offer opinions about possible causes for symptoms, and have to navigate when and how to present this information to their physician. Some patients will preface their symptoms with possible causes and offer lay diagnoses from the beginning. Other patients will wait until the doctor makes a diagnosis and then offer alternate possibilities, ask questions, or disagree with the physician’s diagnosis. Understanding these kinds of social actions, and the phases of interaction they occur within during medical encounters, is crucial to providing empirical findings that might be meaningfully translated into skills needed to provide effective medical care. And it is not only doctor-patient interactions that researchers closely examine, since medical CA also analyzes communication between health care professionals such as physicians, nurses, or insurance providers when discussing issues related to patient care.
Revealing Primary Practices and Patterns of Medical Interactions
By reviewing the fundamental assumptions of CA, Koenig and Robinson (2014) summarize the long history of studying relationships and interactions between health care professionals and patients, and the ability to rely on CA findings when making recommendations for improving communication in the health care industry. The inherent limitations of self-reports about the organization of interactions during medical encounters are also noted. Citing work by DiMatteo, Robinson, Heritage, Tabbarah, and Fox (2003), the majority of self-reports of both patients and doctors did not match up with what was actually said in the interaction. By using CA as the core method for analyzing health care interactions, more compelling evidence is provided about the unadulterated reality of real-time medical interactions—unmarred by limitations of memory, social desirability, and without needing to control for moderating or mediating variables.
Several exemplars are used to demonstrate CA’s ability to identify, analyze, and make use of multiple social actions accomplished by routine physician utterances. The first exemplar addresses the social action of interrogatives, or questions, initiated by physicians in the beginning of medical encounters. When a physician asks a question, the social action performed could accomplish much more than simply inquiring or soliciting information. For example, if a physician asks a patient what he or she can do for them today, this interrogative encourages the patient to present their main health concern. In contrast, other types of physicians’ questions may cause the patient to be uncomfortable, asking a patient to confirm or disconfirm a question, with little request for details about their health condition. Heritage and Robinson (2006b) discovered that when physicians used the first, more open-ended type of interrogative, their patients disclosed a more comprehensive list of symptoms and were more satisfied with their physicians. A second set of exemplars reviewed Heritage and Stivers’s (1999) concept of online commentary, which is communication initiated by the physician describing what he or she is experiencing during the physical exam. This study found that when physicians used “no-problem” utterances, patients were significantly less likely to resist treatment recommendations. Understanding the influence of certain utterances on goals, and medical outcomes, is what makes CA so vital in medical communication research.
Clearly, CA’s strengths involve detailed, accurate, and reliable (i.e., repeatedly inspectable, and available for inter-coder agreement checks) renderings of key moments comprising actual medical interactions. As noted, these strengths are especially important because often there is a discrepancy between what participants report vs. what they actually do or say. One of the largest challenges for conducting CA work is acquiring the necessary time and financial resources to conduct fine-grained investigations of naturally occurring medical encounters. Gaining permission from participants, physicians, hospitals, and organizations can also be a time-intensive venture. So too can it be difficult to gain access, properly utilize the equipment required to film quality video data, and ensure the privacy of those data files.
Intervening and Improving Medical Practice
Robinson and Heritage (2014) catalogue the history of CA’s contributions to intervention studies, arguing that CA can mirror the process of the medical sciences’ randomized controlled trial and offering practical guidelines for future CA intervention studies. When conversation analysts began to provide interventions, these studies resulted in the culmination of workshops, teach-back sessions, and education courses for existing health care professionals. These studies were informal, not because they lacked rigor, but they did not follow the process of a true intervention study. True intervention studies in the medical sciences involve a thorough two-step process of pre-intervention and intervention. This process includes a long list of standardized procedures: determining an evidence base, developing a theory, producing hypotheses, piloting the study, developing testing procedures, evaluating the intervention, disseminating the results, monitoring progress, and continuing to follow up on the study. Historically, randomized controlled studies involving CA and medical encounters are nonexistent (but see Beach et al., 2016; Beach, Buller, Dozier, Buller, & Gutzmer, 2014).
Conversation analysts might disagree with this approach, claiming that mirroring the medical science model compromises important principles of unmotivated CA inquiry (Sacks, 1984). However, an argument is made that the benefits greatly outweigh the costs. One way of addressing the “unmotivated” concern is to recognize that intervention approaches do not make the study any less conversation analytical, but instead simply reframe the scope of investigation by identifying one (or a small number) of key actions and limit focus to those areas. For example, Heritage and Robinson (2006a) were interested in patient-physician interactions about problems that came immediately after patients initiate their concerns. Rather than analyzing a set of materials and finding a theme from the data, a specific theme is predetermined (based on prior studies) and then focused on exclusively.
While a detailed overview for conducting randomized control trials cannot be summarized herein, it is important to draw attention to a few of the basic concerns raised by Robinson and Heritage (2014). First, feasibility is a crucial factor to consider, as it is essential to determine how much data is necessary to determine causality and effectiveness of the medical intervention. Larger sample sizes are preferred by the medical sciences because they reduce the potential for random error. The goal is to determine how to gather the data required for a statistically significant study by using the fewest resources necessary. Conversation analysts interested in conducting invention studies thus need to calculate the duration of the entire project, frequency of data collection on a weekly basis, and resources required (all of which influence project reviews and funding decisions). Second, after determining study feasibility, the next step is to determine a target population. Conversation analysts should consider factors such as groupings of physician specialty, physician subspecialty, level of physician training, visit type, or reasons for visit when selecting a specific target population. Following the selection and CA analysis of a phenomenon, confounding variables should play a role in predicting whether there will be a causal relationship between the intervention and the outcome. Some of these confounding variables might include sex, age, ethnicity, education, and socioeconomic status. And third, following the pre-intervention phase, a larger scale CA trial requires randomizing participants to experimental and control groups, training participants to manage the intervention, and using statistical analyses to determine relationships.
Certain ethical dilemmas should be carefully considered and avoided (if possible). For example, implementation of an intervention could extend visit times, limiting the number of patients a physician can attend to, or unfairly train physicians to ask questions that are awkward or even pressure patients into an answer. Deleting results when the intervention is not carried out as planned is also problematic. For example, physicians may get lost in the moment with their patients, and forget what it was they were supposed to ask—or ask the questions using different wording.
In closing, two case studies are provided that followed the process of a CA-informed pre-intervention, each having potential for being developed into full intervention trials. The first case is coined “prediagnostic commentary,” a label for the foreshadowing of good or bad news (Stivers, 1998). Due to its relevance to general practice medicine, “There was then, fertile ground for pre-intervention CA. That is, there was (a) the possibility of a provider practice, (b) that was linked to a routine medical activity (i.e., physical examination), (c) that had implications for patients’ acceptance of treatment recommendations, and (d) that had potential implications for more distal medical outcomes involving patients’ utilization of treatment recommendations” (Robinson & Heritage, 2014, p. 212). The second case study analyzed is Stivers’s (2007) dissertation work that focuses on resistance trends in treatment recommendations. Patients tended to be more resistant when physicians made negative treatment recommendations. This study is optimal for an intervention because physicians can easily reword their treatment recommendations to have a proactive spin. In an intervention study, physicians can be trained to recommend accomplishable tasks to patients rather than focusing on what tasks should be limited or cut out.
Key Issues and Social Actions across Fifty Years of Medical Research
Integrated access to burgeoning CA research on medical encounters has been an inherent problem. This problem was partially remedied with the publishing of the first edited Handbook of Patient-Provider Interactions, introduced as a compilation of 52 manuscripts chronicling 50 years of significant scholarship on communication during medical interviews (Beach, 2013a). Thirty-one of these studies utilize CA to address a broad range of social actions and interactional circumstances produced by patients and providers when navigating their way through medical consultations. Historically, a significant shift has occurred from biomedical (doctor-centric) to patient-centered orientations to medical care. Rather than giving primary emphasis to patients’ bodily symptoms and diagnosing diseases, increasing attention has been given to the need to address patients’ illness-related concerns including displays of emotions, impacts of life-world experiences (e.g., stress associated with lifestyle, relationships, and finances), complaints, and reasons for visiting doctors. How doctors rely on their authority and expertise when enacting agendas, balancing biomedical with patient-centered priorities, and in turn how (or if) patients subordinate and/or assert themselves during clinical visitations, involves a wide range of social actions that continue to be examined by researchers (e.g., see also Robinson & Heritage, 2015; Robinson, Tate, & Heritage, 2016).
This edited volume is thus organized around key and diverse issues: how patients offer and doctors respond to their concerns; the basic inadequacy of biomedicine; asymmetry, authority, and control; patient-initiated actions (e.g., explanations, expectations, requests, solicitations, and resistance); doctor-responsive actions including attending and disattending issues raised by patients; empathy-in-action (e.g., responding to patients’ emotional concerns); delicate moments during medical interviews (e.g., AIDS discussions, bad cancer news, laughter, antibiotic medications, citing evidence and attributing diagnoses to patients, managing cancer fears, physicians’ opening questions, patients’ assertions of unlikely health conditions); embodied actions (e.g., talk, gaze, gesture, and body orientations); and the importance of communication and consultation skills. Throughout, communication impacts and consequences for health outcomes are also addressed (e.g., compliance, unnecessary return visits, patient satisfaction, malpractice, healing).
Understanding Impacts of Proactive Patients on Medical Care
An increasing focus on patient-centered care raises key questions about how patients negotiate and manage medical authority. How will increasingly informed and assertive patients shape the future of medical care? Beach (2015) reviews considerable evidence suggesting that many patients are not passive recipients who directly respond to doctors’ questions or defer to doctors’ recommendations. As proactive participants, patients may initiate their own questions, directly request specific care options, at times even challenging and resisting doctors’ efforts to diagnose and treat medical problems. Advice offered by doctors may also be rejected. During other moments, cancer patients provide explanations or excuses designed to minimize their sickness by justifying their wellness (e.g., see Beach, 2013), at times minimizing or even avoiding confronting health risks (e.g., lack of exercise, excessive eating or drinking). And when patients withhold providing direct answers, or offer indirect requests, it becomes difficult for doctors to discern what patients really need or want. For example, one recent finding is that the majority of cancer patients’ fearful, uncertain, and hopeful actions are raised indirectly to their oncologists (Beach & Dozier, 2016).
Taken together, these kinds of social actions produced by patients stand in stark contrast to research findings that have historically emphasized patients’ deference and forced reliance on doctors, seeking validation from doctors that they have sufficient reasons for scheduling a visitation, and raising concerns (e.g., questions) only when doctors are ready to hear them (Heritage, 2005). Rather than subordinating to physicians’ agendas, it increasingly appears that patients are becoming more proactive. Increased assertive and even aggressive behaviors may be triggered as patients invest more time online, accessing various websites (e.g., WebMD, American Cancer Society, National Cancer Institute) to read and research possible symptoms and diagnoses for their conditions. Whether patients’ lay understandings of their health condition are accurate or not, making reference to their newfound information, or even claiming knowledge that may be discrepant with doctors’ expert opinions, creates potentially delicate moments when patients’ experiences may conflict with doctors’ authoritative positions. At the same time it is not just possible, but probable, that patients are less willing to accept often inadequate responses from doctors—orientations emphasizing disease-based priorities at the expense of empathy, and sensitivity, to patients’ life-world circumstances (see Epstein & Street, 2007; Heritage, 2005).
Taking Stock of Basic Issues in CA Research on Medical Encounters
A summary is provided in Table 1 of 10 CA researchers’ attempts to frame the historical emergence, current research, and future implications for studying interactions and improving communication during medical encounters.
Table 1. Synthesis of CA Approaches to Medical Encounters
Author, Date, Abbrev. Title
CA in the Medical Encounter
CA and Implications for Clinical Decision Making and Practice
Peräkylä, A. (1997). CA: A new model of research in doctor-patient communication
In contrast, CA can be used “to describe the particular ways in which both parties accomplish their tasks through the sequential organization of interaction” (p. 205), providing richer and more nuanced understandings of medical encounters.
Maynard, D. W., and Heritage, J. (2005). CA, doctor-patient interaction and medical communication
Heritage, J., and Maynard, D. W. (2006). Problems and prospects in the study of physician-patient interaction
Heritage, J. (2009). CA as an approach to the medical encounter
The theoretical underpinnings of CA are discussed.
Robinson, J. D. (2011). CA and health communication
CA can improve traditional coding by:
Gill, V. T., and Roberts, F. (2013). Conversation Analysis in Medicine
Beach, W. A. (2013a). Introduction- Handbook of Patient-Provider Interactions
Koenig, C., and Robinson, J. D. (2014). Understanding the structures of health talk
CA studies should replace existing and future studies using self-reports.
Robinson, J. D., and Heritage, J. (2014). Intervening with CA
Beach, W. A. (2015). Doctor-patient interaction
Across a span of 18 years, strong consensus exists, and collective stances are taken, about the importance of utilizing CA to closely examine medical encounters:
• CA is positioned as the most rigorous method for studying naturally occurring social interaction in ordinary and institutional encounters.
• Compared with alternative methods employed to study medicine (e.g., self-reports, ethnographic and discreet coding studies), CA could integrate (but does not rely exclusively) on data such as individuals’ reports or anecdotes.
• Careful attention is given to overly general and discreet coding categories that (a) are not grounded inductively and empirically in CA data sessions identifying social actions, and (b) do not take into account interactional and sequential environments within which particular social actions are produced.
• Considerable attention is given to describing detailed components of social order evident in and employed by speakers and recipients (e.g., social actions achieved through the design and placement of utterances, turn-taking, and lexical choices within and across sequentially organized interactions).
• Specific features of alternative speech exchange systems, such as medical interviews, can be revealed when using CA to identify the distinctive character of talk and embodied actions when patients meet with doctors, and when health professionals meet with one another to discuss patient care.
• Fundamental importance is attributed to (a) advancing understandings of patient-centered and humane medical care, (b) attending closely to patient-initiated actions, and (c) remaining sensitive to how doctors’ training, knowledge, authority, and constraints (e.g., time and resources for treating patients) get displayed during interviews with patients (and family members).
• Close analyses of single cases, and larger collections of instances, can contribute in meaningful ways to refined understandings of the basic practices and communication patterns evident across all phases (openings-closings) of medical encounters.
• Increasing attention is being given to possibilities, benefits, and challenges of utilizing mixed methods.
• Combinations of basic CA descriptions and explanations, codings anchored in grounded category systems, pre-post measures focusing on specific mediating variables, and utilization of various statistical measurements and tests can become integrated to optimize microanalysis while enhancing generalizability of findings.
• Research protocols with mixed methods can increase the likelihood of funding from state, federal, and private agencies.
• A need exists to design intervention studies, translating basic CA research findings into innovative educational resources for improving medical encounters and related interprofessional interactions.
• A need exists to design and implement large-scale, multisite, randomized control studies with participants randomly assigned to intervention and control (placebo) treatments.
Expanding Horizons: Looking to the Future of CA and Medicine
There are a wide variety of CA research programs and activities focusing on medical encounters that have not been overviewed herein. In addition to research on primary care (e.g., Heritage & Maynard, 2006a), considerable attention has also been given to areas such as pediatric care and concerns with antibiotic prescriptions (e.g., Heritage, Elliot, Stivers, Richardson, & Mangione-Smith, 2010; Stivers, 2007), immunization and vaccine discussions (e.g., Opel et al., 2013, 2012). Visitations between cancer patients and oncologists (e.g., Beach, 2013a; Beach, Easter, Good, & Pigeron, 2005; Lutfey & Maynard, 1998) have also been studied, at times involving discussions with surgeons (e.g., Venetis, Robinson, & Kearney, 2013, 2015). Examinations of palliative and end-of-life care are underway (Beach, Gutzmer, & Dozier, 2015; Parry, 2010; Parry, Land, & Seymour, 2014), as are inquiries into a range of acute and chronic conditions including problems with dementia and memory (Elsey et al., 2015), seizure disorders (Robson, Drew, & Reuber, 2012), antenatal screening (Pilnick & Zayts, 2017), and autism (Hollin & Pilnick, 2015).
The integration of CA into health and medical practice is constantly expanding across an even broader spectrum of care settings, from early studies of AIDS counseling (Peräkylä, 1995) to maternity and child health clinics (Tiitinen & Ruusuvuori, 2014, 2015). Phone calls involving cancer (Leydon, Ekberg, & Drew, 2013) and child protection (Hepburn & Potter, 2003; Potter & Hepburn, 2007) hotlines, nurse-led triage calls, and video recordings about decision-support software (Murdoch et al., 2015), and phone calls between family members facing cancer together over a period of 13 months (Beach, 2009a) have also been analyzed.
These kinds of interactional occasions provide opportunities to closely examine, among other and diverse social actions, how emotions get socially constructed. The emotional well-being of clients is a shared and focal interest when understanding how psychotherapy sessions are interactionally organized (Peräkylä, Antaki, Vehriläinen, & Lauder, 2011; see also Peräkylä & Sorjonen, 2012). In 2016 scholars will gather for the 8th International Conference on Conversation Analysis and Psychotherapy (http://blogs.helsinki.fi/iccap-2016/). Since 2007, four international conferences on Conversation Analysis and Clinical Encounters (CACE) have also occurred, the most recent in 2013 at York University (http://www.york.ac.uk/sociology/about/news-and-events/department/2013/cace-conference/). And in the fall of 2016, Rutgers University hosted a workshop occurring prior to the annual National Communication Association conference. Sponsored by the newly formed Center for Language, Interaction and Health, a two-day Training Workshop on Analyzing Medical Interactions examined work in progress with participants’ recorded and transcribed data.
Professional activities such as these are aligned with goals and priorities of the International Society for Conversation Analysis (http://isca.clubexpress.com/), which promotes interdisciplinary and collaborative research efforts on the structure and dynamics of ordinary (casual) and institutional social interactions.
Three Priorities for Future Research
We conclude by briefly describing three priorities that can facilitate expansion of future CA research, and the dissemination of knowledge and training on medical encounters.
First, increasing priority needs to be given to longitudinal and cross-situational research. The historical tendency has been to record single interviews between patients and providers. The empirical foundation has primarily consisted of episodic descriptions of single cases, built into collections across multiple yet non-continuous encounters. These cumulative insights have generated considerable knowledge about the primary practices and patterns comprising medical interviews. But so doing overlooks the serial ordering of connected events: What does continuity of care look like, across settings and over time? What is the course and progression of interactions designed to diagnose and treat illness and disease? How does an initial interview give rise to follow-up visitations with the same and different providers (e.g., through referrals)? These and related questions are fundamental to emerging research and the growing need for longitudinal research in CA (e.g., González-Martinez, Pekarek Doehler, & Wagner, 2017).
Similarly, most patients spend only minimal time in clinics and when visiting other health professionals (e.g., counselors and therapists). How does information provided during these encounters get reconstructed and updated on the telephone, on various social media (e.g., texts and email), and during conversations in home, work, and related settings? Consider two examples of works in progress: (1) a need exists to trace how genetic counseling sessions get conducted, how patients and family members discuss and reflect on these meetings in home settings when making medical decisions, and eventually how (or if) these concerns get raised and addressed during follow-up counseling sessions (e.g., see Beach, Robinson, & Madlensky, 2016). These are the routine cycles experienced and navigated, by lay persons and professionals alike, who rely on genetic counseling to make informed decisions promoting optimum health for all concerned (e.g., see Zayts & Pilnick, 2014); (2) a one-year documentary film entitled A Journey Through Breast Cancer focuses on communication, a breast cancer patient, and her husband’s journey through diagnosis, treatment (chemotherapy and surgery for single mastectomy), and early phases of remission (Beach, 2018). As time unfolds, these materials include numerous multisite interactions: in the clinic with diverse cancer specialists (e.g., interviews, tumor board meetings), conversations at home about patients’ care and impact on daily living, discussions at patients’ worksite, support group, and across other community settings including phone/Skype conversations. These recordings and full transcriptions are also available for research, using CA to unravel the many complexities of both longitudinal and cross-situational communication throughout cancer journeys.
Second, at this time only two randomized control trials (RCT) have been conducted that are rooted in CA methods and findings: One in the initial stages of studying pediatric care (see Mangione, 2016), the other a recently completed investigation involving not clinical encounters but interactions from family cancer phone calls (Beach, Buller, & Dozier, 2014; Beach et al., 2016). Actual conversations between family members were adapted verbatim into a professional theatrical production entitled When Cancer Calls … (WCC). A primary goal of this RCT was to allow diverse audience members (e.g., patients, survivors, family members, medical professionals) access to, and the possibility of positively being impacted by, conversations from the first recorded natural history of a family managing cancer over 13 months and 61 phone calls. The RCT occurred across 4 major U.S. cities, and comparisons were made between WCC and a control video (lecture) on cancer nutrition and diet. Pretest-posttest sample size was 1006, and a 30-day follow-up and impacts assessment involved 669 participants. Compared with the placebo (lecture), findings revealed that viewings of WCC triggered significant impacts across all 5 family and communication indices, yielded highly significant pretest-posttest change scores (e.g., 775% for self-efficacy, 665% for family fabric, 189% for outside support, and 97% for family communication), and in a 30-day online follow-up, WCC participants reported 30% more conversations about family cancer issues.
The structure and success of this large-scale NIH investigation (144225 01/02) provides a baseline exemplar for (1) how a compelling case can be made for CA as innovative and significant social science; (2) how and why funding is necessary, and can be obtained, to conduct a national study; (3) ways that initial data collection and analysis can be transformed into Phase I Feasibility and Phase II dissemination and effectiveness trials; and (4) how CA-informed research findings can yield highly significant results, with considerable potential for advancing positive impacts and social change regarding the fundamental importance of communication and cancer in contemporary society. To accomplish these goals, a new genre of Entertainment-Education (E-E) was created and implemented. By integrating basic CA empirical findings with the Arts, an everyday language performance was experienced by ordinary persons who evaluated WCC as novel, authentic, and potentially transforming.
Third, important CA findings about patient-provider interactions are most often not developed into tailored curricula for training health and medical professionals. Ongoing, systematic, and longitudinal impact assessments of alternative educational programs, designed to improve medical practice and quality care by enacting humane communicative skills, are in their infancy.
Within the biomedical sciences, translational research often involves unique and sustained bench-to-bedside collaborations between the biopharma industry (e.g., drug development), and clinician-scientists who care for patients while also conducting clinical trials to assess the risks and effectiveness of new healing interventions. Especially for CA researchers employed by hospitals and medical centers, the importance attributed to clinical trials and transdisciplinary collaborations are manifest in the daily operations of treatment and research efforts. How can these efforts increasingly involve CA contributions, and how can university-based researchers form even stronger and more long-lasting collaborations not just with CA colleagues in health settings, but other researchers and administrators who can assist with promoting and conducting basic CA research on medical encounters? How can interactional findings be translated into progressively evaluated and increasingly effective interventions?
Consider WCC as a primary example: What opportunities now exist for further national and global dissemination through innovative educational programs for health, cancer, family, corporate, university, and governmental systems? As CA inquiries on medical encounters continue to diversify and mature, similar translational challenges will arise and require innovative solutions. In what ways do moves toward medical training do justice to original empirical findings? It seems that the more excerpts from actual recordings and transcriptions are used in training, inviting participants to closely examine and be guided through collections of practices and their consequences, the less likely a gap will be created between the world on its own merits and curricula designed to enhance communication skills. Making archived recordings and transcriptions of medical encounters available as a shared resource, such as the One in a Million project at the University of Bristol in the United Kingdom (http://www.bristol.ac.uk/social-community-medicine/people/project/1987), which is focused on patients’ adherence to medical and non-medical treatment advice, is an important step for advancing international research. Findings across diverse researchers’ efforts can then be integrated to build substantive cases about how to manage actions such as treatment recommendations.
Researchers utilizing CA to reveal how key moments are organized throughout medical care will, and increasingly so, be called upon do move from describing and explaining the social world to presenting a range of effective vs. ineffective practices for advancing humane medicine and quality care. Evidence supporting these stances and recommendations will be drawn from both qualitative and quantitative findings, requiring the ability to present positions and arguments about recommendations that will need to be clear and compelling for academics, health professionals, and lay persons alike. And inevitably, suggestions for changing behaviors and educational strategies will be scrutinized, as they should be, for much is at stake for medical and institutional systems responsible for both patient care and sustaining vibrant organizational cultures.
It is clear that the future of CA and medicine is anchored in the continued ability to generate rigorous and important empirical findings about the detailed organization of patient-provider and interprofessional interactions, but also disseminating such knowledge for academics, medical educators, and health administrators who oversee complex health systems. As these collaborations continue to unfold, so too will the development of a hybrid character of CA shaped by an increasing fusion of social interaction, medical research, and training innovations designed to enhance communication and social relationships for all facing illness and disease.
This project was supported by the National Cancer Institute/NCI of the National Institutes of Health/NIH (CA122472, W. Beach, PI).
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