The "unknown territory" of goal-setting: Negotiating a novel interactional activity within primary care doctor-patient consultations for patients with multiple chronic conditions.

Goal-setting is widely recommended for supporting patients with multiple long-term conditions. It involves a proactive approach to a clinical consultation, requiring doctors and patients to work together to identify patient’s priorities, values and desired outcomes as a basis for setting goals for the patient to work towards. Importantly it comprises a set of activities that, for many doctors and patients, represents a distinct departure from a conventional consultation, including goal elicitation, goal-setting and action planning. This indicates that goal-setting is an uncertain interactional space subject to inequalities in understanding and expectations about what type of conversation is taking place, the roles of patient and doctor, and how patient priorities may be configured as goals. Analysing such spaces therefore has the potential for revealing how the principles of goal-setting are realised in practice. In this paper, we draw on Goffman’s concept of ‘frames’ to present an examination of how doctors’ and patients’ sense making of goal-setting was consequential for the interactions that followed. Informed by Interactional Sociolinguistics, we used conversation analysis methods to analyse 22 video-recorded goal-setting consultations with patients with multiple long-term conditions. Data were collected between 2016 and 2018 in three UK general practices as part of a feasibility study. We analysed verbal and non-verbal actions for evidence of GP and patient framings of consultation activities and how this was consequential for setting goals. We identified three interactional patterns: GPs checking and reframing patients’ understanding of the goal-setting consultation, GPs actively aligning with patients’ framing of their goal, and patients passively and actively resisting GP framing of the patient goals. These reframing practices provided “telling cases” of goal-setting interactions, where doctors and patients need to negotiate each other’s perspectives but also conflicting discourses of patient-centredness, population-based evidence for treating different chronic illnesses and conventional doctor-patient relations

A video life-world approach to consultation practice: The relevance of a socio-phenomenological approach

This article discusses the [development and] use of a video life-world schema to explore alternative orientations to the shared health consultation. It is anticipated that this schema can be used by practitioners and consumers alike to understand the dynamics of videoed health consultations, the role of the participants within it and the potential to consciously alter the outcome by altering behaviour during the process of interaction. The study examines health consultation participation and develops an interpretative method of analysis that includes image elicitation (via videos), phenomenology (to identify the components of the analytic framework), narrative (to depict the stories of interactions) and a reflexive mode (to develop shared meaning through a conceptual framework for analysis). The analytic framework is derived from a life-world conception of human mutual shared interaction which is presented here as a novel approach to understanding patient-centred care. The video materials used in this study were derived from consultations in a Walk-in Centre (WiC) in East London. The conceptual framework produced through the process of video analysis is comprised of different combinations of movement, knowledge and emotional conversations that are used to classify objective or engaged WiC health care interactions. The videoed interactions organise along an active or passive, facilitative or directive typical situation continuum illustrating different kinds of textual approaches to practice that are in tension or harmony. The schema demonstrates how practitioners and consumers interact to produce these outcomes and indicates the potential for both consumers and practitioners to be educated to develop practice dynamics that support patient-centred care and impact on health outcomes

GPs’ strategies in exploring the preschool child’s wellbeing in the paediatric consultation

Background: Although General Practitioners (GPs) are uniquely placed to identify children with emotional, social, and behavioural problems, they succeed in identifying only a small number of them. The aim of this article is to explore the strategies, methods, and tools employed by GPs in the assessment of the preschool child’s emotional, mental, social, and behavioural health. We look at how GPs address parental care of the child in general and in situations where GPs have a particular awareness of the child. Method: Twenty-eight Danish GPs were purposively selected to take part in a qualitative study which combined focus-group discussions, observation of child consultations, and individual interviews with GPs. Results: Analysis of the data suggests that GPs have developed a set of methods, and strategies to assess the preschool child and parental care of the child. They look beyond paying narrow attention to the physical health of the child and they have expanded their practice to include the relations and interactions in the consultation room. The physical examination of the child continues to play a central role in doctor-child communication. Conclusion: The participating GPs’ strategies helped them to assess the wellbeing of the preschool child but they often find it difficult to share their impressions with parents

The Impact of Computing Device Design on Patient-Centered Communication: An Experimental Study

Prior research has studied the impact of use of a single computing device, such as a desktop or a tablet computer, on patient-provider communication. While some studies have considered how contextual features such as room layout and software interface design affect computer use and patient-provider interaction in the exam room, it is not known how the choice of computing device impacts patient-provider communication. We conducted a within-participant experimental study. Three physicians participated in nine simulated consultations, using a desktop computer, a tablet computer, and a tabletop computer. Consultations were video-recorded and the video data were analyzed using framework analysis. Findings reveal the choice of device impacts the extent to which the consultation is patient-centered. To better support patient-centered communication, a large adjustable horizontal screen can facilitate eye contact and patient engagement. Findings also highlight the need for design of future systems to consider the characteristics of both openness and privacy

Performance features in clinical skills assessment: Linguistic and cultural factors in the Membership of the Royal College of General Practitioners examination

This book is based on research looking at performance in clinical skills assessment from a linguistic and cultural perspective, with a view to understanding why there are such differential pass rates and giving suggestions on how this issue can be tackled. It is both a research report and a guide to the sociolinguistic methodology used. While the findings are based on a research project in partnership with the Royal College of General Practitioners, they are applicable to many other medical settings where standardised examinations of simulated consultations are used. More widely, this research addresses a central paradox in institutional life – how to balance validity in assessments and be fair to a diverse group of candidates in an increasingly diverse society, while maintaining reliability with standardised and universal marking criteria. It has been widely acknowledged that candidates from overseas fair less well in such examinations. A close look at the interactions which make up these simulated consultations shows that there are complex and subtle differences between passing and failing candidates which cannot be explained simply as ‘language’ and ‘cultural’ differences and put in a box separate from issues of fairness. These structured examinations, unintentionally, contribute to the weight of the assessment on overseas candidates, particularly in how interpersonal effectiveness is judged both explicitly and implicitly. The research has identified a range of successful candidate strategies which form the basis of a set of e–learning materials to be published by the RCGP. It also suggests that aspects of the exam, notably the more subjective features of interpersonal skills, are not best assessed in highly structured exams. This area needs to be better defined, using a new analytic language, to debate how and where it could be most effectively and fairly assessed

Proxy Design: A Method for Involving Proxy Users to Speak on Behalf of Vulnerable or Unreachable Users in Co-Design

Designing digital artifacts is not a linear, straightforward process. This is particularly true when applying a user-centered design approach, or co-design, with users who are unable to participate in the design process. Although the reduced participation of a particular user group may harm the end result, the literature on solving this issue is sparse. In this article, proxy design is outlined as a method for involving a user group as proxy users to speak on behalf of a group that is difficult to reach. We present a design ethnography spanning three years at a cancer rehabilitation clinic, where digital artifacts were designed to be used collaboratively by nurses and patients. The empirical data were analyzed using content analysis and consisted of 20 observation days at the clinic, six proxy design workshops, 21 telephone consultations between patients and nurses, and log data from the digital artifact. We show that simulated consultations, with nurses roleplaying as proxies for patients ignited and initiated the design process and enabled an efficient in-depth understanding of patients. Moreover, we reveal how proxy design as a method further expanded the design. We illustrate: (1) proxy design as a method for initiating design, (2) proxy design as an embedded element in co-design and (3) six design guidelines that should be considered when engaging in proxy design. The main contribution is the conceptualization of proxy design as a method that can ignite and initiate the co-design process when important users are unreachable, vulnerable or unable to represent themselves in the co-design process. Based on the empirical findings from a design ethnography that involved nurses as proxy users speaking on behalf of patients, the article shows that roleplaying in proxy design is a fitting way of initiating the design process, outlining proxy design as an embedded element of co-design

The electronic patient record: a linguistic ethnographic study in general practice

PhDElectronic Patient Records (EPRs) are in widespread use in UK general practice. Although often taken-for-granted by clinicians, managers, administrators and patients, there is limited understanding of how EPRs shape care processes and healthcare interactions in this setting. The EPR is ubiquitous in practice, but its social impact remains under-researched. In this thesis I present a novel approach to examining the role of the EPR, which draws on ethnography and discourse analysis. My work is based on eight months of ethnographic observation in clinical and administrative areas of two general practices. This included observation of clinical consultations, with videorecording of the interpersonal interaction and contemporaneous screen capture of the EPR. This opens up the ‘EPR-in-use’ to detailed scrutiny. In my analysis, which draws particularly on the theoretical work of Goffman and Bakhtin, I pay close attention to the detail of local action and interaction, whilst maintaining sensitivity to the wider context of the general practice organisation. This makes an original contribution to the emerging field of linguistic ethnography. My analysis shows that the EPR contributes to shaping and regimenting interactions and care practices in profound ways, both within the consultation and more widely in general practice organisations. It creates new opportunities, but also creates new demands and tensions. In particular, it sharpens the tension between different ways of framing the patient – the patient as ‘individual’ and the patient as ‘one of a population’ – the latter a more institutional version of the patient. This creates what I have called a ‘dilemma of attention’ for clinicians engaged in patient care. I show ways in which the EPR contributes to the bureaucratisation of care, the construction and circulation of authority within and beyond the consultation, and the production of new notions of patienthood and professional habitus in contemporary general practice

Brief problem-solving treatment in primary care (PST-PC) was not more effective than placebo for elderly patients screened positive of psychological problems

Objectives To evaluate whether screening followed by brief problem-solving treatment by primary care doctors (PST-PC) could improve health-related quality of life (HRQOL) and reduce consultation rates in the elderly. Design A single-blind randomized placebo controlled trial (RCT). Setting Two government funded primary care clinics in Hong Kong. Participants Two hundred and ninety nine Chinese patients aged 60 years or over, with positive screening scores for psychological problems by the Hospital Anxiety and Depression Scale (HADS). Interventions One hundred and forty nine subjects were randomized to receive brief PST-PC from primary care doctors (treatment) and 150 to group video-viewing (placebo). All subjects were followed up by telephone at 6, 12, 26 and 52 weeks. Main Outcome Measures Changes in SF-36 HRQOL scores, HADS scores and monthly consultation rates were compared within and between groups. Results Study completion rates were 69-71%. There was significant improvement in the SF-36 role-emotional (RE) and mental component summary (MCS) scores at week 6 in the PST-PC group but not in the placebo group. Several SF-36 scores improved significantly in the placebo (video) group at week 6-52. Mixed effects analysis adjusting for baseline values and cofounders did not show any difference in any of the outcomes between the PST-PC and placebo (video) groups. Conclusions Screening followed by brief PST-PC was associated with a short-term improvement in HRQOL in Chinese elderly patients screened positive of psychological problems, but the HRQOL benefit was not greater than those found in the placebo group who participated in group-viewings of health education videos. © 2009 John Wiley & Sons, Ltd.postprin