An interactional approach to conceptualising small talk in medical interactions

In medical interactions, it may seem straightforward to identify 'small talk' as casual or social talk superfluous to the institutional work of dealing with patients' medical concerns. Such a broad characterisation is, however, extremely difficult to apply to actual talk, and more specificity is necessary to pursue analyses of how small talk is produced and what it achieves for participants in medical interactions. We offer an approach to delineating a subgenre of small talk called topicalised small talk (TST), derived on the basis of conversation analytically-informed analyses of routine consultations involving orthopaedic surgeons and older patients. TST is a line of talk that is referentially independent from their institutional identities as patients or surgeons, oriented instead to an aspect of the personal biography of one (or both), or to some neutral topic available to interactants in any setting (e.g. weather). Importantly, TST is an achievement of both patient and surgeon in that generation and pursuit of topic is mutually accomplished. In an exploratory but systematic analysis, when this approach was applied to a purposive sample of surgeon-patient interactions, TST was much more prevalent in visits with White than African American patients. Accounts for possible ethnic differences in TST are suggested.     

Theme-oriented discourse analysis of medical encounters

APPROACH: Theme-oriented discourse analysis looks at how language constructs professional practice. Recordings of naturally occurring interactions are transcribed and combined with ethnographic knowledge. Analytic themes drawn primarily from sociology and linguistics shed light on how meaning is negotiated in interaction. Detailed features of talk, such as intonation and choice of vocabulary, trigger inferences about what is going on and being talked about. These affect how interactants judge each other and decisions are made. Interactions also have larger rhetorical patterns used by both patients and doctors to persuade each other. EXAMPLES: Two settings are used to illustrate this approach: genetic counselling and primary care consultations in multilingual areas. In genetic counselling, interactions are organised around the tension between the risks of knowing and the risks of occurrence. This can lead to a 'rhetorical duel' between health professionals and patients and their families. In intercultural primary care settings, talk itself may be the problem when interpretive processes cannot be taken for granted. Even widely held models of good practice can lead to misunderstandings under these conditions. CONCLUSION; Through discourse analysis, the talk under scrutiny can be slowed down to show the interpretive processes and overall patterns of an activity. Discourse analysts and health professionals, working together, can look at problems in new ways and develop interventions and tools for a better understanding of communication in medical life.     

The reality of role-play: interruptions and amount of talk in simulated consultations

Context The language and structure of doctor–patient consultations have been widely researched. Although simulated patients (SPs) are much used in communication skills teaching, the language of the simulated consultation has not received much attention. Objectives This study aimed to resolve the following questions. How are interruptions and numbers of words distributed in simulated consultations? Do they correlate with set variables (e.g. gender, scenario) or outcome variables (e.g. grade)? Methods A total of 100 videotaped assessed consultations between SPs and Year 3 medical students were transcribed. Words by each participant were counted, and interruptions were coded and counted. Amount of talk and interruptions were chosen because they are potential markers of conversational dominance. Results We found that SPs talk (55% versus 45% for students) and interrupt (74% versus 26% for students) significantly more than medical students. The scenario is significantly associated with the number of words and interruptions. Multivariable testing shows that female SPs are associated with more words. The number of words is significantly and positively associated with examination grade. The number of student interruptions is significantly and positively associated with grade. Conclusions Because the simulated consultation takes place in an institutional setting, the SP may have institutional power over the student. This may explain how findings from these role‐play interactions differ from actual doctor–patient consultations. This suggests that simulated consultations are educational devices rather than exact representations of doctor–patient interactions. The authors hope this paper will contribute to a discussion about the nature of role‐play in medical education.     

Participation in the medical consultation: the co-ordination of verbal and nonverbal behavior between the doctor and patient

The following paper is concerned with the coordination of verbal and nonverbal behaviour by the doctor and patient in the medical consultation. It explores the relationship between the talk of the patient and the nonverbal behaviour of the doctor and demonstrates how the gaze direction of the doctor plays a crucial part in the articulation of an utterance by the patient. In examining a series of examples drawn from primary health care consultations, the analysis reveals how patients, or more generally speakers, use gestural activity to realign the gaze of their recipient(s) and encourage their participation in talk. In this fashion the paper addresses the problem of how the participants maintain a state of mutual involvement and sustain their integration within social interaction.     

Participation in the medical consultation: the co-ordination of verbal and nonverbal behaviour between the doctor and patient

The following paper is concerned with the coordination of verbal and nonverbal behaviour by the doctor and patient in the medical consultation. It explores the relationship between the talk of the patient and the nonverbal behaviour of the doctor and demonstrates how the gaze direction of the doctor plays a crucial part in the articulation of an utterance by the patient. In examining a series of examples drawn from primary health care consultations, the analysis reveals how patients, or more generally speakers, use gestural activity to realign the gaze of their recipient(s) and encourage their participation in talk. In this fashion the paper addresses the problem of how the participants maintain a state of mutual involvement and sustain their integration within social interaction.     

Decreasing the number of consultations for minor illnesses of Turkish and Dutch inhabitants of a deprived area in The Netherlands: an intervention study

OBJECTIVE: The purpose of this study was to assess the effectiveness of GPs personally handing out to their patients booklets about minor ailments and self-limiting health problems (minor illnesses). METHODS: The study was a pre-test-post-test, control group design and took place in seven general practices. The participants were 162 patients (72 Turkish, 70 Dutch and 20 of other nationality) who frequently visit their GP (>5 times a year), living in deprived areas of The Hague. They were recruited in the waiting rooms of participating general practices. GPs personally handed out booklets to their patients about 12 of the most common minor illnesses and explained how to use them. The main outcome measures were consultations for the 12 minor illnesses listed in the booklet, reported by the patients themselves as well as registered in the general practice medical records, and the number of self-reported illnesses the patients suffered from. RESULTS: The results of both the self-report and the medical records show a significant decrease in number of consultations for minor illnesses in the entire research population, Turkish as well as Dutch. The number of self-reported self-limiting health problems of the Dutch increased. CONCLUSION: Due to the non-randomization procedure, some caution with regard to generalization must be taken. The results indicate that distribution by the GP of booklets with tailored information when a patient is ill leads to a reduction in consultations for minor illnesses.     

'Unilateral' and 'bilateral' practitioner approaches in decision-making about treatment

Practitioners can present and discuss decisions about the management of health problems in a variety of ways during consultations. This paper examines in detail how doctors talk with patients in relation to decision-making about treatment. Conversation analyses of decision-making sequences in consultations about diabetes in primary care and about treatment of ear nose and throat (ENT) cancer in a specialist oncology setting, both in the UK, revealed a spectrum of practitioner approaches ranging from more 'bilateral' to more 'unilateral'. This paper identifies the key communicative and organisational features of these approaches and provides some preliminary observations about the implications of these for patient participation in decision-making.     

Teaching and learning about human sexuality in undergraduate medical education

BACKGROUND: Effective management of the doctor's role in relation to human sexuality requires sensitivity and tact, an ability to put patients at ease, use of appropriate language, and therapeutic, non-discriminatory attitudes. However, previous research suggests that medical students and doctors may hold negative attitudes towards homosexuality and some forms of sexual behaviour. Some educational programmes have started to help students develop communication skills for sexual health consultations, but little work has addressed the broader issue of attitudes and values which may underlie behaviour. It is vital that medical students begin early the process of reflection and recognition of how their attitudes and values might influence their care of patients. In this paper we report on a course designed to initiate this process at Leicester-Warwick Medical School (LWMS). COURSE DESCRIPTION: The course utilizes techniques of desensitization, problem-solving and reflection to enable the students to achieve the learning outcomes, which are primarily oriented towards reflection and self-development. It uses a variety of teaching and learning strategies, combining peer learning with self-directed learning, and small-group learning with whole class learning. COURSE EVALUATION: We report observations and a before-and-after questionnaire study of students' views and attitudes. This evaluation suggests that the course is successful in reducing students' anxieties about human sexuality and improving their confidence in developing appropriate skills. CONCLUSIONS: The LWMS course is one model which might be used to begin the process of encouraging medical students to develop ways of appropriately managing their responsibilities in relation to human sexuality.     

Approaches to the measurement of explanation and information-giving in medical consultations: A review of empirical studies

Many ‘sociological’ and ‘medical’ reasons for informing and not informing patients in medical consultations have been given. This paper reviews and evaluates various empirical attempts to support arguments about the relationship between information-giving and outcomes. It suggests that more attention has been paid to examining the way information is given than to the information itself. When information has been examined this has been in relatively ‘empiricist’ ways, ignoring the issue as to how illuminating it might be. The paper concludes both that we know very little about the causes and consequences of information exchanged in medical consultations and that we are unlikely to do so unless different approaches are attempted.     

Mothers, daughters and sexual agency in one low-income South African community

Statistics indicate that sexual health problems like HIV/AIDS and teenage pregnancies are prevalent among young South African low-income women. To improve the effectiveness of preventative programmes for adolescents it is important to focus on adolescents' own understanding and experience of their sexual behaviour within the contexts in which it occurs. Female adolescents' experiences of their own sexuality are shaped by a range of contexts: from the very specific context of their intimate relationships to the broader contexts of gender, ethnicity and social class. It is therefore imperative to adopt a research approach that stratifies groups and develops interventions that are based on the needs, interests, sexual beliefs and behaviours of specific communities rather than developing general educational messages. The current paper is part of a larger study exploring female adolescent sexuality in a South African low-income rural coloured community. Twenty-five adolescent coloured women aged 14-18 years were interviewed about how they viewed their sexuality. The grounded theory analysis indicated that the participants demonstrated a limited sense of sexual agency in these constructions of their sexuality. The mothers of these young women were powerful agents in the young womens' constructions of their own sexuality and they unintentionally contributed to their daughters' limited sense of sexual agency. Mothers presented sex as a dangerous activity to their daughters. This discourse of sex as danger contributed towards a mutual understanding that sex should not be talked about. Daughters' deception of their mothers about their sexual activity maintained mother-daughter connections, but left them without an interactional space where they could talk freely to their mothers about sexuality.     

Breast talk in breast cancer narratives

Breast cancer often involves uniquely mutilating treatments and is frequently assumed to produce problems specifically associated with feminine identity: body image and sexuality. But empirical research to support this assumption is sometimes mixed and nearly always quantitative in method. This study examines breast talk--specific references to breasts and breast cancer in women's illness narratives--collected in 20 open-ended, in-depth interviews with 17 White, middle-class survivors in Maine. Participants varied in age, marital status, motherhood sexual orientation, family history of breast cancer, medical diagnoses, and treatments. Phenomenological analysis of the breast talk resulted in four interrelated clusters of meanings: the medicalized breast, the functional breast, the gendered breast, and the sexualized breast. The analysis suggests both greater and fewer problems with femininity, sexuality, and body image than presumed by much research, and it urges researchers not to reproduce the objectifications and stereotyping of sexist culture.     

A Mixed Method Study Investigating the Impact of Talking about Patients’ Internet Use on Patient-Reported Outcomes

This study aims to propose and test a model that provides a more comprehensive understanding of the impact of discussing online health information on patient outcomes. By combining survey data (N = 160) and qualitative analysis of video recordings of consultations (N = 165) with structural equation modeling, this study explores: (1) whether patients and health-care providers talk about online medical information and (2) the impact of talking about online medical information on patient outcomes (patient satisfaction, recall of medical information, and medication adherence). Results show that more than half of the patients searched online prior to their consultation. In about half of these consultations (46.81%), the online information was discussed. Patients were more satisfied with the consultation if the online information was discussed during the consultation. Moreover, patient satisfaction was positively related to recall of medical information, but only in patients with whom the online information was discussed. There was no effect found on medication adherence. Results of this study demonstrate the importance of talking about online information during a consultation for improving patient outcomes. Implications for research are discussed.     

Doctor-patient communication: a comparison of the USA and Japan

BACKGROUND: Little is known about the differences and similarities between doctor-patient communication patterns in different cultures. OBJECTIVES: The aim of this study was to examine communication patterns of doctor-patient consultations in two different cultures, namely the USA and Japan, and to elucidate linguistic differences and similarities in communication. METHODS: This cross-sectional study used quantitative discourse analysis from linguistics to compare 40 doctor-patient consultations: 20 out-patient consultations of five physicians in the USA and 20 out-patient consultations of four physicians in Japan. The main outcomes measured were time spent in each phase of the encounter, number of categorized speech acts, distribution of question types and frequencies of back-channel responses and interruptions. RESULTS: The average length of doctor-patient encounters was 668.7 s in the USA and 505 s in Japan. US physicians spent relatively more time on treatment and follow-up talk (31%) and social talk (12%), whereas the Japanese had longer physical examinations (28%) and diagnosis or consideration talk (15%). Japanese doctor-patient conversations included more silence (30%) than those in the USA (8.2%). The doctor-patient ratios of total speech acts were similar (USA 55% versus 45%; Japan 59% versus 41%). Physicians in both countries controlled communication during encounters by asking more questions than the patients (75% in the USA; 78% in Japan). The Japanese physicians and patients used back-channel responses and interruptions more often than those in the USA. CONCLUSIONS: While doctor-patient communication differed between the USA and Japan in the proportion of time spent in each phase of the encounter, length of pauses and the use of back-channel responses and interruptions, physician versus patient ratios of questions and other speech acts were similar. The variations may reflect cultural differences, whereas the similarities may reflect professional specificity stemming from the shared needs to fill the information gap between physician and patient. Adequate awareness of these differences and similarities could be used to educate clinicians about the best approaches to patients from particular cultural backgrounds.     

The expression of aversion to medicines in general practice consultations

Although the relevance of patients' views about medicines for their medicine taking behaviour is now well established, little is known about the ways in which these views are discussed in primary care consultations. In particular, many studies have demonstrated patients' aversion to medicines. This paper examines the form that aversion talk takes in the consultation and how doctors respond to patients' expression of aversion to medicines. It is based on a dataset of 35 case studies of general practice consultations in England. In interviews with researchers, aversion to medicines was expressed in 34 of the 35 cases. In consultations with doctors, aversion was expressed in 10 cases. The interactional dimension of aversion talk in consultations was analysed using Conversation Analysis, and two general patterns were identified. Aversion could be used as an interactional resource, or it could be a topic in its own right. If used as an interactional resource, no real discussion of patients' views of medicines took place. When aversion was a conversational topic in its own right, two situations were observed. Firstly, the doctor elicited patients' views directly. Secondly, patients initiated aversive talk using a range of indirect strategies to do so. Even when patients managed to express their aversion to medicines, doctors did not engage them in any real discussion of their views. A scheme of interpretation is suggested to explain these findings. In this scheme patients perceive medicines to be an extension of the doctor and to be beneficial. In this view it is right for doctors to prescribe medicines and for patients to take medicines. The results of this paper suggest that using aversion as an interactional resource might be the only safe way for patients to express their aversion without seeming to breach the social contract.     

Lower Adherence: A Description of Colorectal Cancer Screening Barrier Talk

Understanding how patients and physicians discuss screening barriers may illuminate reasons for non-adherence to recommended colorectal cancer (CRC) screening. The goal of the present study was to describe patients’ reporting of and physicians’ responses to CRC screening barriers and examine their associations with patients’ CRC screening behaviors. Audio-recorded primary care consultations (N = 413) with patients due for CRC screening were used to identify CRC screening-related barrier talk and physician responses. Presence of barrier talk was associated with less patient adherence to CRC screening (OR = 0.568, p = 0.007). Neither CRC screening talk (n = 413) nor physician responses (n = 151) were associated with patients’ CRC screening. Among the consultations in which barrier talk occurred (n = 151), patients most often reported test-related (28.9%) and psychological (26.1%) barriers. Barriers were most often reported in the context of CRC screening discussions (45.7%) or in direct response to a physician’s question about CRC screening (48.6%). Results indicated that patients rarely raised CRC screening barriers unprompted and that presence of barrier talk was predictive of CRC screening behavior. These findings may help improve future clinical practice by highlighting that patients may benefit from physicians initiating and facilitating discussions of CRC screening barriers and directly helping patients overcome known barriers to CRC screening.     

Touching the private parts: how gender and sexuality norms affect medical students’ first pelvic examination

Gynaecologists are in a position to challenge norms about gender and sexuality in relation to female genitals. Through their work they have the opportunity to educate patients, which is why teaching medical students to perform examinations in a gender sensitive way is significant. Medical students performing their first pelvic examination often experience the examination as uncomfortable because it is a body part that is connected to sex and to something private. This paper uses medical students’ interpretations of performing their first pelvic examination as a means to discuss how cultural norms for gender, sexuality and female genitals affect these examinations. Issues raised include how cultural connotations of female genitals affect the pelvic examination, how female and male students relate differently to examining female genitals and the interpretations they make in relation to themselves. Findings show that the female genitals are perceived as a special body part connected to sexuality and intimacy. Students’ gender also affects the interpretations they make during pelvic examinations. Norms of gender, sexuality and female genitals need to be challenged in the teaching and performance of pelvic examination in order to demystify this experience.     

GPs' attitudes to minor ailments.

BACKGROUND: It is generally considered that a significant proportion of 'inappropriate' demand for GP services is generated by consultations for minor ailments. How GPs manage minor ailments is likely to affect how patients perceive and handle similar illnesses in the future. Whilst this potentially has significant implications for general practice workload, research investigating GP' attitudes towards minor ailments and their management is sparse. OBJECTIVE: Our aim was to describe GP' experiences and perceptions of minor ailment consultations and their attitudes towards minor ailment management. METHODS: A questionnaire survey was conducted in 1999, derived from a series of 20 qualitative interviews with practising GPs. The survey was sent to one GP randomly selected from each practice (n = 759) in eight English health authorities. Attitudinal statements were analysed using factor analysis. RESULTS: Four hundred and fourteen GPs (54.5%) completed and returned the questionnaire. Respondents were consulted regularly about minor illness or symptoms, with almost all (95.6%) having experienced a minor ailment consultation in the previous week. Factor analysis suggested four issues to be of importance in determining GP' attitudes to minor ailment management. These were attitudes towards pharmacists, attitudes towards patient empowerment, frustration with minor ailment consultations and attitudes towards caution/risk. CONCLUSION: Although GPs are clearly frustrated by the level of minor ailment consultations, this study suggests that there may be complex factors which influence their attitudes. For the optimal management of minor ailments, inter-professional relationships potentially are of great importance. With increasing patient demand, it is essential that finite health care resources are accessible, appropriate and used in an optimal way.