A conversation analytic intervention to help neurologists identify diagnostically relevant linguistic features in seizure patients’ talk

Recent Conversation Analytic work has revealed that there are systematic differences between the ways in which patients with epilepsy and patients with “psychogenic” non-epileptic seizures (NES) describe their seizure experiences. But these differences may not become apparent if patients are exposed to traditional fact-oriented questioning. This article describes a oneday intervention workshop, informed by Conversation Analysis, which was designed to help doctors change their history-taking style and solicit diagnostically useful narrative features. A comparison of video-recordings of 38 routine consultations before the intervention, and 20 consultations after it, showed that the intervention had the desired effect. Doctors' problem presentation solicitation changed, and the patient responses were better suited to revealing diagnostically-relevant features of their talk. Data in British English

How and why children instigate talk in pediatric allergy consultations: A conversation analytic account

Involving children in their healthcare encounter is a national and international priority. While existing research has examined the ways in which children are recruited to participate in the consultation, no work has examined whether and how children instigate talk, and the extent to which their contributions are successful. This paper presents a conversation analysis of a selection of 10 out of 30 video recordings in which children aged 4-10 years instigate talk during consultations they attend with their parents/carers at a UK pediatric clinic. The analysis reveals for the first time that children do successfully instigate talk without being asked or selected in 22 episodes during their consultation with the doctor. Children most frequently address their parent/carer (16/22). They capitalize on specific contexts within the consultation to instigate talk, for example: history-taking questions about what they ate or how they reacted (10/22); or discussions surrounding the child’s feelings or sensations following the skin-prick testing (7/22) - aspects of experience to which they have access. Children’s non-solicited talk necessarily occurs when they are not currently active participators and children engage in extra interactional work including various verbal strategies (summons and prosodic variations) and non-verbal resources (tapping and gaze) to break into the interaction. The benefits of their contributions include the opportunity to affirm the child’s role as a legitimate contributor, and the potential for additional medically-relevant information to arise which could enrich the clinical process. Our analysis shows that the previously overlooked phenomenon of children instigating talk, although not common, can play a crucial role in the consultation. We suggest that strategies to increase such involvement have the potential to augment the healthcare process. Our findings offer a critical baseline for the introduction of new consultations models, such as digital appointments, which may exclude some children completely

Rape myths, jury deliberations, and conversation analysis: a new approach to an age-old problem

Rape and serious sexual offences (RASSO) are gendered crimes with high rates of prevalence, yet a multitude of barriers contribute to low rates of reporting to the police (Taylor & Gassner 2010). For those who do report, very few cases successfully progress through the criminal justice system due to high attrition rates, and various ‘evidential difficulties’, and even fewer result in a conviction (Willmott et al, 2018; 2021). [...]</p

Communication in pediatric healthcare: a state-of-the-art literature review of conversation-analytic research

Communication is central to pediatric care. Conversation analytic (CA) studies of recorded naturally occurring pediatric interactions contribute distinctive understandings; however, to date there has been no detailed review of CA’s unique contributions. We searched Medline, PsychINFO, Sciencedirect, Google Scholar, and the EM/CA Wiki database, identifying 74 empirical articles across diverse areas of pediatrics. Our state-of-the-art review highlights CA of clinician and caregiver conversations about a child patient, in addition to those involving the child. The findings have the potential to enhance clinical practice by illuminating how healthcare tasks are practically accomplished and enrich our knowledge of children’s participation in consultations by revealing the mechanisms that constrain and enable their involvement. We call for better synthesis of findings with broader CA literature (e.g., nonclinical child interactions, adult triadic clinical encounters, and fundamental knowledge of social interaction). We appeal for increased support for scholarly work in non-Western settings, and emphasize scope for applied initiatives. The data reported are in multiple languages. </p

Rape myths, jury deliberations, and conversation analysis: a new approach to an age-old problem

Rape and serious sexual offences (RASSO) are gendered crimes with high rates of prevalence, yet a multitude of barriers contribute to low rates of reporting to the police (Taylor & Gassner 2010). For those who do report, very few cases successfully progress through the criminal justice system due to high attrition rates, and various ‘evidential difficulties’, and even fewer result in a conviction (Willmott et al, 2018; 2021). [...]</p

Providing opportunities for patients to say more about their pain without overtly asking: a conversation analysis of doctors repeating patient answers in palliative care pain assessment

As the main symptom in palliative care, pain requires careful assessment. Repeating patient answers is one recommended communication technique for helping convey to patients that they have been heard, and to encourage them to say more. We examined 23 episodes where experienced doctors repeat patients' answers with mirrored rhythm and downward-final intonation, captured in pain assessments video-recorded in 37 consultations in a large UK hospice. Using conversation analysis, our aim was to determine whether or not the repeats invite additional talk, and if so, how they do so. Our findings reveal lexical and prosodic features of doctors’ repeated pain answers that signal completion of the sequence. At the same time, because the patient has greater epistemic access to their own pain, a repeat can also invite confirmation or disconfirmation. The patients in our data sometimes—but not always—respond to the repeat with confirmation or further talk. We conclude that repeating patient answers with mirrored rhythm and downward-final intonation provides a no-obligation opportunity for patient-led confirmation, disconfirmation, or expansion of pain descriptions, particularly when the pain matter is new, revised, or has been problematic to report.<br

“Are you otherwise fit and well?”: past medical history questions in UK paediatric consultations

Accurate diagnosis and treatment depend upon detailed knowledge of both the child’s presenting symptoms and their past medical history. However, the process of soliciting past medical history has never been subject to systematic scrutiny in actual clinical practice. Objective: To examine the function of the question “are you otherwise fit and well?” to elicit a child’s general medical history in UK paediatric allergy outpatient consultations. Methods: Examination of 30 video-recorded UK paediatric outpatient consultations involving children (2–10 years), caregivers, and one doctor. We identified, transcribed, and interrogated 13 examples, deploying the systematic and rigorous method of conversation analysis to elucidate the question’s micro-design elements and their consequences for the consultation’s trajectory. Results: Asking “Are you otherwise fit and well?” is built to efficiently solicit a problem-free report of good health. Nonetheless patients can and do raise other relevant matters. In practice, the question initiates several interactional matters simultaneously: establishing/resolving (mis)understandings of “fitness” and “wellness”; negotiating opportunities for children’s participation; and importantly, a shift towards discussing more general wellbeing. Conclusion: Past medical history questions unavoidably generate broader interactional matters which are skilfully resolved in real-time between clinicians, caregivers, and children. Practice implications: Clinical training could be greatly enhanced by integrating insights into the interactional consequences of asking questions, particularly in the complex multiparty environment of paediatrics. While the question ‘Are you otherwise fit and well’ clearly serves an important function, clinicians should be alert to the possible problems it might raise, especially when directed towards younger children.</p

RealTalk evidence-based communication training resources: development of conversation analysis-based materials to support training in end-of-life-related health and social care conversations

Training to enhance healthcare practitioners’ capabilities in engaging people in sensitive and end-of life-related conversations is in demand. However, evaluations have either not measured, or found very limited impact on actual practice and patient experience. Training effectiveness is improved when it is based on in-depth evidence, reflects the complexity of real-life interactions, and instils principles adaptable to everyday practice. A relatively new source of in-depth evidence and practice-relevant insights on healthcare interactions is conversation analytic research, a form of observational analysis of real-life interactions. However, conversation analytic research findings have largely been disseminated by and for scientists, rather than clinicians and trainers. We used conversation analytic evidence to develop resources for use by healthcare trainers. The aim was to increase training’s evidence-base and authenticity. We further aimed to develop resources applicable to working with learners ranging from novices to advanced practitioners. Methods: Using an intervention development approach, we created online video-clips and supplementary written materials for professionals who deliver training, supervision, and support in healthcare communication for staff and students. The materials were reviewed by an advisory group comprising clinicians, lay consultees, educators, and researchers, and piloted by trainers in UK universities, NHS organisations and independent hospices. We refined materials based on their feedback. Results: The resulting ‘RealTalk’ resources focus on practices for communicating with patients and their companions about end-of-life and prognosis. Two core training modules were developed, each comprising several patient case studies featuring video-clips from real-life healthcare consultations. The clips featured practices that patients and experienced practitioners use in approaching end-of-life matters. The case studies also included evidence-based descriptions of observable practices and the principles underlying these, alongside transcripts and case synopses. Conclusions: RealTalk training resources aim to facilitate evidence-based, experiential and reflective learning, focusing on communication challenges, practices and principles for end-of-life-related interactions. The resources are designed for use by trainers for delivering all levels of training, from introductory to advanced, in both formal and informal training settings. Our development process may serve as a blueprint for the production of future evidence-based training resources based on conversation analytic research.</p

Communicating with patients and families about illness progression and end of life: a review of studies using direct observation of clinical practice

Background: There is growing recognition that a diverse range of healthcare professionals need competence in palliative approaches to care; effective communication is a core component of such practice. This article informs evidence-based communication about illness progression and end of life through a rapid review of studies that directly observe how experienced clinicians manage such discussions. Methods: The current rapid review updates findings of the 2014 systematic review focussing more specifically on evidence related to illness progression and end-oflife conversations. Literature searches were conducted in nine bibliographic databases. Studies using conversation analysis or discourse analysis to examine recordings of actual conversations about illness progression or end of life were eligible for inclusion in the review. An aggregative approach was used to synthesise the findings of included studies. Results: Following screening, 26 sources were deemed to meet eligibility criteria. Synthesis of study findings identified the structure and functioning of ten communication practices used in illness progression and end-of-life discussions. Conclusion: The ten practices identified underpin five evidence-based recommendations for communicating with patients or family members about illness progression and end of life

End of Award Report February 17TH 2016: VERDIS: Video-based communication research and training in supportive and palliative care

High quality staff-patient communication is central to compassionate, effective healthcare. There has been limited progress towards generating robust evidence about the precise structure and functioning of healthcare communication. This impedes development of effective interventions and their evaluation. Conversation analysis, which relies on audio- and video-recordings of naturally occurring healthcare episodes is making rapid advances, particularly in generating evidence about communication in primary care medicine. The conversation analytic approach was used in this study to generate underpinning knowledge about the structures and functioning of healthcare communication behaviours in specialist palliative care, and to design associated staff communication skills training materials. In this study, we focused on communication in specialist palliative care provided in a hospice. Good communication is central to high quality effective care for people nearing the end of life and their friends and relatives [1, 2]. Poor communication is associated with distress and complaints [3, 4]. Also, we know that one particular element of communication in this domain - discussing and making plans and decisions about future care - influences place of death, and aggressiveness of care [5, 6], but little is known about precisely how staff can support patients to engage with such sensitive, challenging discussions, and about how to do so in an empathic manner. Thus we studied decision-making communication and communication associated with empathy – a quality highly valued by patients and their companions [7]. We know that patients and professionals are reluctant to address sensitive issues and decisions about the future and that practitioners’ uncertainty about how to talk with patients and family members about these is an important obstacle [8]. In an international survey of 90 palliative care experts, 80% wanted more evidence-based guidance on optimal communication strategies to improve decision-making practice [9]. There is already an established communication skills training programme for healthcare professionals – the ‘Connected’ advanced communication skills training programme, which is based within regional cancer networks, and funded through local commissioning [10, 11]. This kind of training is primarily delivered to staff who work in oncology and specialist palliative care. Systematic reviews indicate these courses have some positive effects [3], but that these are confined to two particular behaviours: trainees’ expression of empathy and question-asking behaviours. Unfortunately, no benefits have been shown in terms of patients’ communication behaviours and their perceptions of communication quality; also evidence about long-term effectiveness is contradictory [3]. Furthermore, current training is based upon limited evidence: little derives from direct observations [10], and most is specific to cancer patients [11]. There is good reason to anticipate stronger effects were it grounded in more detailed evidence about communication behaviours and skills [10, 12-14]. This study aimed to generate such detailed evidence, with data and analysis not solely confined to discussions with people with cancer. Video-based research on communication is relatively new within healthcare research, but is already developing a track record of yielding useful findings, for instance, it has identified specific communication practices that enhance patient satisfaction [15], and that increase vaccine uptake rates [16]. Video-based conversation analytic research has also led to design of communication training and interventions that have been shown to be effective in improving healthcare consultations – for instance in enabling primary care patients to express more of their concerns within consultations with doctors [12], and people attending HIV clinics to express their concerns more succinctly and readily [17]. Thus we know that video-based research on recordings of ‘real’ patients and professionals yields benefits to patients. However, it is not yet known whether using video-recordings of ‘real’ rather than simulated interactions in communication training increases its effectiveness and thus leads 5 to improvements in staff-patient communication; we will address this important question within the research programme of which the current study forms part. In this study we sought to generate evidence about how experienced, specialist hospice doctors communicate with patients and their accompanying friends/relatives, and design staff communication training materials aiming to pass on those skills to less experienced, less specialist staff. The resultant materials include video-clips of real interactions (where all participants permitted this use of their recordings); these were piloted in communication skills training at 11 sites and a preliminary evaluation conducted on trainees’ and trainers’ perspectives on perceived value, acceptability and usability