Transcript PPT - The Center For Language Acquisition

Patients offer ‘unlikely’ explanations
for their symptoms
Anita Pomerantz
Department of Communication
University at Albany
[email protected]
Summer Institute of Applied Linguistics
Penn State University, July 2009
Contextualizing My Research
Growing body of CA research focuses on resources and practices that
patients employ during clinic visits
Response to research that treated doctors as calling all of the shots
Aligned with movement for patient-centered practice
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Patient Resources
Ask questions
Seek clarification
Hint or ask for medical tests
Hint or indirectly ask for medications
Shape descriptions of their medical problems
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Patient Resource – Propose Candidate Explanation
Patients not only report on their symptoms; they share their
reasoning about their symptoms. [How and why?}
Uncertainty markers display orientation to roles, differential rights
May explicitly state candidate explanation or imply it via symptom
descriptions (Stivers, 2002, 2007)
Generally use formats that do not establish conditional relevance in
next turn (Gill, 1995, 1998)
Generally present ‘likely’ candidate explanations, unless otherwise
marked
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Reasons for presenting ‘likely’ candidate explanations
Display themselves as knowledgeable and involved in own care
(Pomerantz and Rintel, 2004)
Show problems are doctorable (Heritage and Robinson, 2006)
Angle for particular treatment, e.g. antibiotics (Stivers, 2002)
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Relevance of Phases
Phases offer different opportunities for, and impose various constraints
on, patients’ participation.
The ways in which patients present their candidate explanations of
their illnesses are phase-specific.
The phase bears on what actions the patients do when they offer
candidate explanations and the responses.
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Phases of the outpatient medical clinical visit
Six phases (Heritage & Maynard, 2006)
Opening
Presenting complaint
Examination
Diagnosis
Treatment
Closing
More general characterization of phases
Physician collects data through verbal and/or physical exam
Physician analyzes data and presents findings (diagnosis)
Physician offers advice about treatment or management
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First Study
Preemptive Resistance: Patients’ participation in diagnostic sensemaking activities (Gill, Pomerantz, Denvir, in press)
Natural environment for resistance to diagnosis
Preemptiveness
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Diagnostic Phase – Natural place for response to Dx
After doctor offers diagnosis, patient may align with, or resist, it.
Patient may align via agreeing assessment.
Doctors treat patients’ minimal acknowledgments, continuers,
and silence as alignment.
Aligning indicates willingness to move on.
Patients may resist in outright fashion or suggest different diagnoses.
Patients may resist tacitly by reporting symptoms and bodily
states that are inconsistent with the diagnoses.
Resisting encourages delaying the progression of the visit.
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Data Collection Phase
Patients have opportunities to present their interpretations when they
describe their medical problems.
Often they report explanations framed as likely or probable.
With likely explanations, patients can draw doctors’ attention to potential
causes and hint, suggest, or forthrightly ask them to consider them during
the visit.
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But why do patients present unlikely candidate
explanations? How do they function?
Patients have different purposes for presenting different sorts of ‘unlikely’
candidate explanations.
Explore what patients are doing when they raise benign or mundane
candidate explanations and present evidence against those explanations
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Data
Examined 50 consultations drawn from 3 data sets:
Late 1980s internal medicine clinic in Midwestern teaching hospital
Early 1990s in ambulatory clinic in teaching hospital in large Eastern city
Early 2000 in a family practice clinic located in a mid-sized Eastern city
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Methods
Conversation Analysis
Examined recordings of medical visits along with detailed transcripts
Analyzed how persons employ shared interactional resources to
accomplish social actions and activities.
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Preemptive Resistance
Presenting benign candidate explanation, then casting it as unlikely
In information gathering phase, patient talks about a problem or symptom
and raises a candidate explanation (X)
Patient resists candidate explanation by providing evidence that X is not
the cause or by suggesting there is no evidence to support X as the cause.
Optionally, the patient also may add an upshot that explicitly rules out X.
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Example - offer benign explanation, frame as unlikely
Patient describes feet swelling as a medical problem
Patient introduces summer heat as a candidate explanation
Patient offers evidence against summer heat as a likely explanation
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Present benign candidate explanation and frame it as unlikely
[18:1211 (25:27)]
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Dr:
Pt:
Dr:
Pt:
Dr:
U::m (.) let's see:. Couple of other things that
you've checked o:ff (0.7) .hh >you mentioned<
some::ah (1.5) ankle °swelling?°
Pch .h You know my feet never used to swell at all.
In fact that was one of the things I always got iv:(0.2) was admired by everybody.=How come you can take
your shoes o(h)ff and you(h)r feet never swell. .HH
You know. .hh And the la:st couple of months=an
course it's summer.[An it's] °hot.°[.hhh] You know:.
[M hm ]
[M hm]
A::hw (.) but my FEET have swelled.
And I:[N:: ]E:Ver °had that b[efore.°]
[M hm]
[M hm? ]
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Functions of arguing against benign candidate explanations
Patient implies candidate explanation is unlikely to be worthy of
investigation.
Patient implies doctor should look elsewhere for diagnosis without
going on record to promote serious options.
In implying rather than stating a serious option, patient can avoid possible
attribution of jumping to worst case scenario.
Having considered and rejected commonplace explanation casts problem
as puzzling and “doctorable (Heritage & Robinson, 2006).
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Doctor’s reaction to summer heat as unlikely cause
[18:1211 (25:27)] Continued
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Dr:
Pt:
Dr:
Pt:
Dr:
Does it seem like everything is catching up with you?
Ye::ah.
hhhh ((Doctor is smiling.))
All the things that people have had all these years
and suddenly I get them and they fall on me you know.
.hhh(0.8) Think I gotta start using my umbrella or
something.
(4.5)
.hh Kay, then the other:- the other thing you
mentioned was:: (.) you have (.) pain with
intercours:e..
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Preemptively arguing against benign candidate explanation
Patients raise and resist candidate explanations in advance of
diagnostic informing, when doctors still are gathering information
In this early phase, patient offer descriptions of problem together with
his/her sense of what is not causing the problem to occur.
Location and format allows doctor to continue the medical work-up in
light of the evidence patient provided rather than to respond immediately.
Potential problem: when doctor continues to gather information, it may not
be transparent whether contribution influenced the trajectory of the inquiry.
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Second Study
When patients present serious health conditions as unlikely:
managing potentially conflicting issues and constraints
(Pomerantz, Gill, Denvir, 2007)
Discourse reflects conflicting issues and constraints
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Presenting serious candidate explanation as unlikely
Intrigued by the following observations
Patients seemed invested in raising candidate explanations while also
invested in arguing against them.
Patients often used elaborate packaging to present the ‘unlikely’ candidate
explanation.
There was ambiguity or minimization regarding their level of
concern.
Each patient succeeded, if not on the 1st try then on the 2nd, to
direct the doctor’s attention to the candidate explanation.
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Overview of Excerpt
Patient describes medical problems
Patient raises “bladder infection” as a candidate explanation
Patient raises “appendix” as a candidate explanation
Patient raises “a lot of gas” as a candidate explanation
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Adding to the overview of excerpt
Patient describes medical problems
Patient offers bladder infection as likely candidate explanation
not serious, likely
Patient offers appendicitis as a serious candidate explanation, and
presents evidence against it serious, unlikely
Patient offers a lot of gas as a benign candidate explanation, and
presents evidence against it benign, unlikely
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Patient describes the problem, offers ‘likely’ explanation
Doc:
Pt:
Pt:
Doc:
Pt:
Pt:
Doc:
Pt:
Doc:
Uh why- wh:y are you um at the clinic today=what seems
to be the [problem.]
[(W’ll) I] ha- I have this pressure in my uh
lowuh stomach,
(1.0)
And uh: slightly (stiff) I cain’t (0.7) you know (.) (hardly-) can’t
hardly walk like I shou:ld.
Mm hmm,
You know,
(1.0)
When I go to ba:throom (um) uh (1.7) it’s u:h (1.5) (like) stings a
little,
Mm [ hmm ]
[(And uh)] (1.0) it may be a bladder condition=I’ve had dat
before,
You’ve had that bef- (tha]t’s)
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How the patient created an opportunity to raise
candidate explanations
Early phase of visit, in slot provided by doctor’s soliciting reason for visit
Described symptom (pressure), indicated its severity, then offered
another symptom commonly associated with bladder infection
In that environment, she offered “bladder condition” as 1st of
several candidate explanations.
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Patient offers likely explanation, unlikely serious explanation,
and unlikely benign explanation
Pt:
Doc:
Pt:
Pt:
Doc:
Pt:
Doc:
Pt:
Doc:
Pt:
Pt:
(And uh)](1.0) it may be a bladder condition=I’ve had dat before,
You’ve had that [bef- (tha]t’s)
[An’ then] (0.7) I thought it was my appe:ndix=I
don’t know I d- guess (I) wouldna’ la:st this long=I woulda’ h- had
(0.2) woulda’ had tuh be here before now.
(0.2)
I don’ know=an’ den .hh I hadda’ lot of ga::s.
Mm [hmm]
[You] know but it (0.2) seem to be die:in’ down=but uh- I still
have this pai:n inna lower s:tomach.
Right.
And y’ see here you see how I be walkin’
Mm h[mm]
[ H]mm .hh
(.)
An’ u:m den I had uh pains in my chest
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1st discourse features that reflect conflicting concerns
Before raising appendicitis as possibility, patient presents bladder condition
as likely possibility.
What if she had presented appendicitis as her first or only candidate
explanation?
Presenting multiple candidate explanations, with the serious one in noninitial position, is potential solution to conflicting concerns:
Raising appendix as a possibility for doctor’s consideration WHILE ALSO
presenting self as person who does not embrace worst case scenario.
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2nd discourse features that reflect conflicting concerns
Patient provides her reasoning - but only tentatively.
An’ then] (0.7) I thought it was my appe:ndix=I don’t know I d- guess (I)
wouldna’ la:st this long=I woulda’ h- had (0.2) woulda’ had tuh be here
before now. (0.2) I don’ know
Presenting patient’s medical reasoning with uncertainty markers is a
solution to conflicting concerns:
Presenting self as able to reason about likelihood of appendicitis WHILE
ALSO orienting to differential rights regarding medical expertise.
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3rd discourse features that reflect conflicting concerns
Patient portrayed appendicitis as unlikely, but did so with marked
uncertainty.
After no immediate response to “appendix,” patient ruled out benign
explanation “a lot of gas.” Further presents unsolved puzzle.
Portraying candidate explanation as unlikely while displaying uncertainty
about it and puzzlement is a solution to conflicting concerns:
Prompting the doctor to attend to that candidate explanation WHILE ALSO
taking the stance that it is unlikely to be the case.
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Doctor’s responses to candidate explanations
Doctor acknowledged 2 of the 3 candidate explanations
Bladder condition: “You’ve had that bef- (that’s)”
Lot of gas: “Mm hmm” and “Right”
With no acknowledgement of appendix talk, patient would not know
whether or not doctor would attend to it as a possible diagnosis.
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2nd presentation of appendicitis as candidate explanation
Patient created an opportunity to re-raise appendix
When doc was moving to close questioning about possible bladder
infection and start questioning about her chest pain, patient jumped in,
with no gap, to again raise appendicitis.
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Doc:
`
Pt:
Pt:
Pt:
Doc:
Pt:
Doc:
Pt:
Doc:
Pt:
Doc:
Pt:
Doc:
Pt:
Doc:
.hh U:h (0.2) any burning when you urinate?
(1.0)
M:aybe a little (
)
(1.0)
Maybe (
) (0.2) I don’ know.
(0.5)
until I (1.0) (s’posed to) u:rinate in a cup like
[an’ ] ‘en they take the [uh]
[Yeah]
[Ye]ah I- I’ll take a look at your urine
i- in a little bit and we’ll see if that’s what’s (.) what’s goin’ on=
=I jus’ hope it wasn’t no appendix.
Okay.=
=Was what I was worried [about. ]
[Tha- th]at seems to be your major
concern whether (.) whether it’s [an appendix.]
[(
] )
[Yeah]
[An’ I] had uh (0.2) cesarian (.) too=
=Mm hmm
With eight children
Okay (.) well we’ll- we’ll sort it out when I examine you we’ll
see uh (.) u:h (0.5) i- if that’s a possibility
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Patient re-raised candidate explanation
while orienting to conflicting concerns
1st occasion patient framed appendicitis as ‘improbable.’ On 2nd occasion,
she expressed emotions of concern and worry (past and present tense)
“I jus’ hope it wasn’t no appendix”
“Was what I was worried about”
Confirms that her “major concern” is whether it was appendix.
Expressing concern way of re-introducing appendix such that doc
would attend to that possibility.
In reporting worries/concerns, used entitlement to know and report
own feelings while respecting doc’s medical expertise, entitlements.
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Doctor’s response to candidate explanation
Inasmuch as doctors direct their attention to patients’ stated worries,
their expression should succeed in directing the doctors’ attention.
In diagnostic phase, doctor referred back to patient’s concern, gave
multiple reasons for ruling out appendicitis, reassured patient to not worry.
Likely the extent to which he reassured patient was a response to patient’
invoking worry to reinteroduce appendix.
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Concluding Remarks
While doctors have rights to medical expertise and largely direct the
consultation, patients also can have influence in the consultation.
By raising and ruling out benign candidate explanations, patients may
direct doctors attention to more serious possibilities without going onrecord to articulate them.
By raising a serious candidate explanation and presenting evidence
against it, patients may direct doctors’ to address those possibilities
while presenting themselves as knowledgeable and reasonable.
With benign explanations, patients imply ‘Look elsewhere.” With serious
explanations, patients seek reassurance that that isn’t the diagnosis.
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Implications for doctors
Difficult to interpret whether patient currently is concerned or not, and
whether to address something that sounds like its ruled out. Framing
may be shaped for interactional considerations.
When patients attempt to further their agendas, more elaborate turn and
sequence organization are needed. Patients need time to develop
complex narratives and reports.
Patient have resources to express their interests, often indirectly. Also
although it takes more interactional work, they have resources to
pursue when their interests are not heard on a first occasion.
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Patients offer ‘unlikely’ explanations for their symptoms
Thank you
Anita Pomerantz
Department of Communication
University at Albany
[email protected]
Summer Institute of Applied Linguistics
Penn State University, July 2009