Hedging,knowledge and interaction: Doctors’ and clients’ talk about medical information and client experiences in genetic counseling

Objectives

The article starts from the observation that professionals in genetic counseling deploy the strategy of ‘hedging’. It shows how hedging is used in a particular sequential position: doctors’ responses to clients’ presentations of personal information during information delivery sequences.

Methods

The data consist of video-recorded sessions of genetic counseling. The methodology is based on ethnomethodological conversation analysis. The analysis identifies interactional patterns in the counseling sessions.

Results

In their responses doctors display an orientation to different access to different kinds of knowledge. In particular, the doctors tread carefully when commenting on the situation of a particular client vis-á-vis the symptoms and prognosis of genetic conditions. Furthermore, the article shows that the doctors’ responses and hedging devices in them are fitted to the form and function of the clients’ presentations of personal experience.

Conclusion

While the focus of the article is narrow in that it concentrates on one type of an interactional sequence, its strength is that it shows how the doctor's talk can be intertwined with the client's contributions.

Practice implications

The results make it possible for genetic counselors to identify an interactional task they recurrently face and reflect on alternative ways of responding to it.     

Executive function and conversational strategies in bilingual aphasia

Background: Deficits of executive function (EF) have been proposed as all or part of the underlying mechanisms of language impairment in at least some types of aphasia. Executive functions also play a role in the recovery process. There is evidence that bilingual persons have some executive functioning advantages compared to monolingual persons. In this paper we combine two lines of recent investigation in order to explore the relationship between executive function and conversational strategies in bilingual aphasia.

Aims: The aim of this preliminary research was to compare the executive functioning profiles of bilingual individuals to those of monolingual participants with aphasia. A further aim was to examine evidence in the conversational samples of the participants in relation to the application of a range of executive skills and to link cognitive and conversational profiles using Barkley's (1997) model of executive functions.

Methods & Procedures: The performance of two bilingual individuals with aphasia on a test battery of executive function tests was compared with that of eight monolingual persons (seven with aphasia and one with right hemisphere damage). The test battery included measures of behavioural inhibition, working memory, problem solving, and reconstitution. The presence or absence of executive features in the conversational samples of the participants was judged by four raters using conversational analysis methods.

Outcomes & Results: Significant differences were found between the scores of the bilingual participants and those of the monolingual participants on measures of behavioural inhibition, working memory, planning and problem solving, and reconstitution. The bilingual participants' scores were mostly within normal limits and suggested well‐retained executive functions. Conversation analysis showed evidence of differential application of these executive functions to conversational management. Regardless of severity or type of aphasia, the bilingual participants showed evidence of good topic management, repair, and flexibility compared to the monolingual participants.

Conclusions: The results are interpreted in relation to current issues in bilingualism. Our preliminary findings shed light on differential approaches to assessment, therapy, and choice of language for bilingual aphasia.     

Measuring the social interactions of people with traumatic brain injury and their communication partners: The adapted Kagan scales

Background: Considerable attention has been given to the nature of communication impairments of individuals with TBI (Coelho, 2007 Coelho, C. A. 2007. Management of discourse deficits following traumatic brain injury: Progress, caveats, and needs. Seminars in Speech & Language, 28(2): 122–135.  [Google Scholar]; Ylvisaker, Turkstra, & Coelho, 2005 Ylvisaker, M., Turkstra, L. S. and Coelho, C. 2005. Behavioral and social interventions for individuals with traumatic brain injury: A summary of the research with clinical implications. Seminars in Speech & Language, 26: 256–267. [Crossref], [PubMed] , [Google Scholar]). However, there have been few data focusing on the way communication partners deal with the often distressing sequelae of TBI.

Aims: This study reports inter- and intra-rater reliability of the Adapted Measure of Support in Conversation (MSC) and Measure of Participation in Conversation (MPC) for TBI interactions.

Method & Procedures: The MSC and MPC were adapted to reflect theoretical models of cognitive-communication support for people with TBI. A total of 10 casual and 10 purposeful TBI interactions were independently rated by two raters to establish inter-rater reliability and by one rater on two separate occasions to determine intra-rater reliability.

Outcomes & Results: Excellent inter-rater agreement was established on the MSC (ICC?=?0.85–0.97) and the MPC (ICC?=?0.84–0.89). Intra-rater agreement was also strong (MSC: ICC?=?0.80–0.90; MPC: ICC?=?0.81–0.92). Over 90% of all ratings scored within 0.5 on a 9-point scale.

Conclusions: This is the first scale to measure the communication partner during TBI interactions. It shows promise in evaluating communication partner training programmes.     

The complexities of speaking for another

Background: While it is recognised that conversation partners of people with aphasia often speak for them, investigation of “speaking‐for” incidents has shown that these comprise a wide range of behaviours, leading Simmons‐Mackie, Kingston, and Schulz (2004 Simmons‐Mackie, N., Kingston, D. and Schultz, M. 2004. “Speaking for another”: The management of participant frames in aphasia.. American Journal of Speech‐Language Pathology, 13: 114–127. [Crossref], [PubMed], [Web of Science ®] , [Google Scholar]) to identify a “fine interactive line” (p. 123) between “speaking for” and “speaking instead of”. To date, however, there has been little exploration of these behaviours in the context of everyday family conversation; furthermore, little is known about how family members themselves interpret the actions of speaking for their relative with aphasia.

Aims: The goal of this paper is to describe how the husband of a woman with progressive nonfluent aphasia (PNFA) and their adult children experienced and interpreted his ways of speaking for her.

Methods & Procedures: Findings are drawn from a qualitative case study exploring a family's experiences of progressive aphasia through analyses of their talk. Methodology included a thematic analysis of in‐depth interviews conducted with each of six family members and conversation analysis of their everyday conversations together, selected and audio recorded by the participants themselves over a 3‐month period.

Outcomes & Results: The husband's “speaking‐for” behaviours, which emerged as a significant theme in the interview data from him and all four adult children, were linked to long‐standing patterns of interaction but were described as problematic in the context of his wife's aphasia. Conversation analysis revealed that he used three patterns of “speaking‐for” behaviours, each with different interactional strategies and consequences.

Conclusions: Discussion highlights the nuances, challenges, and complexities of “speaking for” behaviours when considered in the historical context of relationship.     

Judging conversation: How much is enough?

Background: Perceptual ratings provide a means of evaluating conversations involving individuals with aphasia. The influence of sampling segments of conversation and of segment length has not been established.

Aims: To investigate the impact of the duration of the conversational segment on judges' perceptual ratings of elements of conversations between individuals with aphasia and their conversation partners.

Methods & Procedures: A total of 64 speech pathology student judges rated two previously video-recorded conversations, elicited through a video-retelling task, between two individuals with severe aphasia and their respective partners via the Measure of Skill in Supported Conversation and the Measure of Participation in Supported Conversation (Kagan et al., 2004 Kagan, A., Winckel, J., Black, S., Duchan, J. F., Simmons-Mackie, N. and Square, P. 2004. A set of observational measures for rating support and participation in conversation between adults with aphasia and their conversation partners. Topics in Stroke Rehabilitation, 11: 67–83. [Taylor & Francis Online] , [Google Scholar]). Each judge was randomly assigned a segment from one or both conversations. The segment lengths were 3 minutes, 5 minutes, 10 minutes (for the longer conversation only), and the entire conversation (10:30 minutes and 19:17 minutes). The effect of segment duration and the interaction between conversation and segment duration were analysed for each rating scale using a 2?×?3 factorial analysis of variance.

Outcomes & Results: There was no significant main effect for segment duration for any of the four rating scales of the Measure of Skill in Supported Conversation and the Measure of Participation in Supported Conversation.

Conclusions: Aphasiologists who utilise these ratings of conversation as outcome measures can base the ratings on a segment of the conversation rather than the entire conversation. A 3- or 5-minute segment of a longer conversation on which no time limit has been placed is adequate to provide an accurate perceptual judgement.     

叙事医学模式结合看图对话工具在2型糖尿病高危足患者中的干预研究

目的研究叙事医学模式结合看图对话工具在2型糖尿病高危足患者中的应用效果。方法选取2017年11月至2018年11月连云港市中医院糖尿病科收治的80例2型糖尿病高危足患者作为研究对象,并按照随机数表法将其随机分为观察组(40例)与对照组(40例),其中观察组患者采用叙事医学模式结合看图对话工具进行健康教育,对照组患者采用传统授课方式进行健康教育,对比观察两组患者足趾畸形、甲沟炎、足麻木、足皲裂等发生情况,温度觉、振动觉、压力觉、痛觉与下肢动脉血流异常情况,以及焦虑自评量表(selfrating anxiety scale,SAS)评分和抑郁自评量表(self-rating depression scale,SDS)评分。结果护理干预后,观察组患者甲沟炎与足皲裂发生例数较对照组明显减少,差异具有统计学意义(χ~2=5.591、5.952,P=0.018、0.015),温度觉、振动觉、压力觉、痛觉与下肢动脉血流异常发生例数均明显少于对照组,差异具有统计学意义(χ~2=6.054、8.455、6.146、4.114、6.146,P=0.014、0.004、0.013、0.043、0.013);护理干预后,观察组患者SAS评分及SDS评分均明显低下对照组,差异具有统计学意义(t=3.629、13.559,P=0.001,0.001),且两组患者SAS评分及SDS评分与干预前相比均显著降低,P均0.05,差异具有统计学意义,结论叙事医学模式结合看图对话刁工具能够有效改善2型糖尿病高危足患者的足部相关症状,缓解其焦虑、抑郁情绪。     

Relational interaction in occupational therapy: Conversation analysis of positive feedback

Background: The therapeutic relationship is an important factor for good therapy outcomes. The primary mediator of a beneficial therapy relationship is clinician–client interaction. However, few studies identify the observable interactional attributes of good quality relational interactions, e.g. offering the client positive feedback.

Objective: The present paper aims to expand current understanding of relational interaction by analyzing the real-time interactional practices therapists use for offering positive feedback, an important value in occupational therapy.

Methods: The analysis is based on the conversation analysis of 15 video-recorded occupational therapy encounters in psychiatric outpatient clinics.

Results: Two types of positive feedback were identified. In aligning feedback, therapists encouraged and complimented clients’ positive perspectives on their own achievements in adopting certain behaviour, encouraging and supporting their progress. In redirecting feedback, therapists shifted the perspective from clients’ negative experiences to their positive experiences. This shift was interactionally successful if they laid the foundation for the shift in perspective and attuned their expressions to the clients’ emotional states.

Conclusions: Occupational therapists routinely provide their clients with positive feedback. Awareness of the interactional attributes related to positive feedback is critically important for successful relational interaction.     

Trouble and repair during conversations of people with primary progressive aphasia

Background: Primary progressive aphasia (PPA) affects a range of language domains that impact on communication. Little is known about the nature of conversation breakdown in PPA. The identification of trouble in conversation, its repair and the success of repairs has been used effectively to examine conversation breakdown in neurogenic language disorders such as dementia of the Alzheimer type (DAT) and acute onset aphasia. This study investigated trouble and repair in the conversations of people with PPA.

Aims: The first aim of this study is to describe the contributions of individuals with PPA and their conversation partner to conversation. The second aim is to describe the trouble that occurs in dyadic conversations between three individuals with PPA and their communication partner. The third aim is to describe the repair behaviours used by the individuals with PPA and their communication partners.

Methods & Procedures: Dyadic conversations about everyday activities between three individuals with PPA and their partners and three control dyads were video recorded and transcribed. Number of words, number of turns and length of turns were measured and trouble-indicating behaviours (TIBs) and repair behaviours were categorised.

Outcomes & Results: Individuals with PPA had reduced mean length of turn but maintained their share of turn-taking. They demonstrated a variety of TIBs that differed from the noninteractive repairs, which do not require a response from the partner in the conversation and which have been observed in studies of conversation in DAT. Their partners bore the greater burden of highlighting trouble and need for repair using collaborative, interactive, TIBs. Three different conversational profiles were observed in the three PPA dyads, reflecting different patterns of language and cognitive impairment.

Conclusions: Individuals with PPA were active participants in conversation effectively indicating and responding to trouble. Understanding trouble and repair in the conversations of individuals with PPA has the potential to enhance assessment and inform clinical practice.     

The duality of option-listing in cancer care

ObjectiveListing more than one option for treatment, termed “option-listing” (OL) is one way to facilitate shared decision-making. We seek to evaluate how oncologists do option-listing in clinical encounters across disease contexts.MethodWe coded and transcribed 90 video-recorded interactions between 5 oncologist participants and a convenience sample of 82 patients at 2 large clinics in the western U.S. We used conversation analytic (CA) methods to examine patterns of behavior when oncologists provided more than one treatment option to patients.ResultsIn early-stage disease, OL provides patients with options while at the same time constraining those options through expression of physician bias. This effect disappears when cancer is at an advanced stage. In this context, OL is presented without physician preference and demonstrates recission of medical authority.ConclusionIn early-stage contexts, OL functions as a way for physicians to array available options to patients while also communicating their expertise. In advanced-stage contexts, OL functions as a way to minimize treatment options and highlight dwindling possibilities.Practice implicationsOL is one way to implement shared decision-making, but it can also be used to facilitate a realization that treatment choices are diminishing and disease is progressing beyond a cure.