"We need to discuss surgery": A multimodal conversation analytic study of intersubjectivity during surgeons' information provision to patients

Abstract

Providing patients with information, such that they are able to understand the consequences of treatment decisions, is an ethical and legal requirement in New Zealand and many other jurisdictions. While research from the disciplines of bioethics, law, and medicine has shown that patients’ recall and understanding of what they have been told is often limited, such research has focused on the “what” rather than the “how” of informing. While some health communication and health literacy research has addressed the how of informing, such research has relied on observation and coding strategies. By contrast, this thesis project addresses the how of informing via situated interactional analysis. Information provision creates many challenges for both patients and surgeons. One of the greatest challenges is epistemic asymmetry, which is exacerbated by low health literacy and numeracy. To provide context for my findings in the analytic chapters, I describe the conflicting institutional, social, and psychological demands that surgeons face when providing information to patients. In addition to epistemic asymmetry, these include adherence to legal precepts, upholding bioethical principles, establishing and maintaining social relations, dealing with uncertainty, countering the “curse of expertise”, and forming a mutually acceptable plan for next steps within the circumscribed time frame of a surgical consultation. In this thesis, I use multimodal conversation analysis to investigate participants’ management of intersubjectivity during surgeons’ extended tellings. Drawing on prior conversation analytic research on intersubjectivity and repair, the structure of storytellings, epistemics, and turn taking, I show that surgeons’ information provision takes the form of extended tellings during which patients say little. Although the content of these tellings varies widely, the content categories, namely Problem, Process, Alternatives, and Risks, which are familiar to me as a former clinician, are similar across most of these tellings. Furthermore, the ordering of these content categories appears designed to scaffold patient understanding. On the one hand, while structural aspects of extended tellings generally inhibit floor-taking turns by patients, my research reveals that some surgeons use recycling of previous talk to create “unit ends”. Some patients orient to these unit ends by providing full turns-at-talk that initiate repair or display their stance. Furthermore, their full turns (can) provide demonstrations of their understanding. In the event that they reveal misunderstandings, such demonstrations allow surgeons to tailor their repairs. Notwithstanding the sequential implicativeness of repeats as unit ends, patients’ floor-taking turns are rare in the mid-telling environment. However, patients can claim they are following surgeons’ talk via head nods and minimal vocal responses in the vicinity of TCU completions. In keeping with prior research, my findings show that, providing there is mutual gaze, surgeons in my data usually treat the absence of such on-time acknowledgements as interactional trouble. This orientation is evidenced by progressivity disruptions in the form of post-positioned expansions, reformulations, understanding checks, increments, response pursuits, or reassurances. While demonstrations of understanding are rare during these extended tellings, patients can upgrade their claims of epistemic access via complex multimodal gestalts, either to claim new understanding or to claim epistemic antecedence. In this regard, analysis shows that the timing of patients’ modal moves (such as nods), in relation both to other modal moves (such as gaze continuation or withdrawal) and to surgeons’ TCU completions, is key to the epistemic affordances created. Prior research has shown that gaze is central to intersubjectivity management because of its roles in mutual monitoring and in interactional engagement/disengagement. In keeping with this research, my findings emphasise the role of gaze in creating the accountability of patients’ acknowledgements at surgeons’ TCU completions. Furthermore, in keeping with prior research, surgeons in my data use gaze both for response pursuit and recipient selection. Finally, my analysis shows that the epistemic affordances of patients’ complex multimodal gestalts depend on gaze withdrawal or continuation. In addition to the above theoretical contributions, my multimodal transcription method makes a methodological contribution by facilitating reader access to the simultaneous unfolding of modal moves and gaze direction. Moreover, this thesis has the potential to contribute to training of surgeons and other experts involved in information provision to laypersons. The essence of my thesis argument, which is based on a combination of empirical multimodal conversation analytic research and the ethnographic insights of a former clinician, is that the central issue with informing for informed decision making is the ever-present tension between interactional intersubjectivity and progressivity. However, despite surgeons doing nearly all the talking during extended tellings for information provision, these tellings are co-operatively constructed by the interactional participants