RESUMEN
Against Medical Advice (AMA) discharges pose significant challenges to the healthcare system, straining patient-clinician relationships while contributing to avoidable morbidity and mortality. Furthermore, though these discharges culminate in patients' departure from hospitals, their effects reverberate long after, propagated by clinician notes stored in patients' medical records. These notes capture exceptionally fraught interactions between patients and providers, describing the circumstances surrounding breakdowns in clinical relationships. Additionally, they represent just one side of complex, contentious social interactions, for in describing AMA discharges, clinician notewriters quite literally have the last word. For these reasons, notes documenting AMA discharges provide insight into the ways in which clinicians conceptualize, characterize, and propagate power differentials in the contemporary healthcare system. Here, we present a qualitative thematic analysis of 185 notes documenting AMA discharges from a large urban US medical center, interpreting note dynamics through three sociological models of power analysis: (i) the distributive model of power promulgated by Max Weber, (ii) the collectivist power model characterized by Talcott Parsons and Hannah Arendt, and (iii) structural interpretations of power developed by Michel Foucault. We argue that in documenting AMA discharges, clinicians appear to conceive of their relationship with patients in almost exclusively distributive terms, which in turn contributes to an adversarial dynamic whereby both patients and clinicians ultimately suffer disempowerment. We furthermore argue that by facilitating clinicians' recognition of power's collectivist and structural dimensions, we may help transform breakdowns in patient-clinician relationships into opportunities for collaboration.
Asunto(s)
Alta del Paciente , Poder Psicológico , Humanos , Alta del Paciente/estadística & datos numéricos , Relaciones Médico-Paciente , Investigación Cualitativa , Negativa del Paciente al Tratamiento/psicología , Negativa del Paciente al Tratamiento/estadística & datos numéricos , Femenino , Masculino , Persona de Mediana Edad , Estados UnidosRESUMEN
Patients are more engaged in their healthcare than ever before, including in the process of diagnostic sensemaking. But in acute primary care encounters, the interactional flow of the visit is shaped by an orientation toward the physician as the authority over diagnostic reasoning. Once physicians close diagnostic inquiry and transition into counseling, their assessment - and the extent to which it converges with the patient's perspective - comes into full view. Yet this is precisely when patients have reduced occasions to speak up if they do have concerns, as the "train has left the station" both diagnostically and interactionally. Using conversation analysis and a dataset of 75 video recordings of acute primary care encounters in the US, this article examines how patients speak up in this constrained environment. The concept of diagnosis demurral is proposed to describe how patients resist diagnostic closure by renewing the relevance of diagnostic inquiry, either in response to a diagnosis or at any point following the transition into counseling. Findings suggest that patients demur more frequently than prior studies on diagnosis resistance may have predicted, but they do so in ways that maintain deference to the physician's authority over matters of diagnosis: speaking up primarily outside the diagnostic moment, relying on actions in their own domain of expertise (e.g., their illness experience), and working to additionally soften the epistemic and interactional inappositeness of their demurral. This behavior sits at the nexus of two opposing forces: patients may be more engaged, but their participation is constrained by a continued legacy of medical authority over diagnosis, to which patients themselves continue to respond and reproduce.
Asunto(s)
Comunicación , Procesos de Grupo , Humanos , Instituciones de Salud , Pacientes , Atención Primaria de SaludRESUMEN
OBJECTIVES: Despite decades of communication training, studies repeatedly demonstrate that clinicians fail to elicit patients' agendas. Our goal was to provide clinicians with actionable guidance about the effectiveness of agenda-soliciting questions. METHODS: We coded clinician agenda-soliciting questions and patient responses in audio-recorded ambulatory encounters at an urban academic hospital. To evaluate the association between question type and odds of the patient raising a concern, we performed mixed-effects logistic regression. RESULTS: We identified 346 agenda-soliciting questions within 138 visits (mean 2.51/visit; range 0-9). Agenda-soliciting questions were categorized as personal state inquiries (37%, "How are you?"), feeling-focused (5% "How're you feeling?"), problem-focused (12%; "Are you having any problems"), direct solicitations (3%; "Anything you want to discuss today?"), "what else" (3%), "anything else" (14%), leading (16%; "Nothing else today?"), and space-reducing (11% "Anything else? Smoking?"). Patients raised a concern in response to 107 clinician questions (27%). Patients were more likely to raise a concern to direct solicitation (OR 22.95, 95% CI 2.62-200.70) or "what else" (OR 4.68, 95% CI 1.05-20.77) questions. CONCLUSIONS: The most effective agenda-soliciting questions are used least frequently by clinicians. PRACTICE IMPLICATIONS: Clinicians should elicit patient agendas by using direct language, and solicit additional concerns using "what else" vs. "anything else" questions.
Asunto(s)
Comunicación , Emociones , Humanos , Lenguaje , Registros , FumarRESUMEN
CONTEXT: Patients taking direct-acting oral anticoagulants (DOACs) may be at risk for bleeding if they take interacting over-the-counter (OTC) products, yet little information exists about why patients may or may not seek information about potential interactions. OBJECTIVE: To investigate perspectives of patients taking apixaban (a commonly prescribed DOAC) regarding seeking information about OTC products. STUDY DESIGN and ANALYSIS: Semi-structured interviews were analyzed using thematic analysis. SETTING: Two large academic medical centers. POPULATION: English-, Mandarin-, Cantonese-, or Spanish-speaking adults taking apixaban. OUTCOME MEASURES: Themes associated with information-seeking about potential apixaban-OTC product interactions. RESULTS: Forty-six patients aged 28-93 years (35% Asian, 15% Black, 24% Hispanic, and 20% White; 58% women), were interviewed. Respondents took 172 total OTC products, of which the most common were: vitamin D and/or calcium (15%), non-vitamin non-mineral dietary supplements (13%), acetaminophen (12%), NSAIDS/aspirin (9%), and multivitamins (9%). Themes related to lack of information-seeking about OTC products included: 1) failure to recognize that apixaban-OTC product interactions might exist; 2) beliefs that providers are responsible for disseminating information about interactions; 3) previous suboptimal interactions with providers; 4) infrequent OTC product use; and 5) lack of prior problems with OTC product use (with or without concomitant apixaban use). Conversely, themes associated with seeking information included: 1) believing that patients are responsible for their own medication-related safety; 2) greater trust in providers; 3) unfamiliarity with the OTC product; and 4) prior medication-related problems. Patients noted that information sources ranged from in-person sources (e.g., physicians, pharmacists) to online and written materials. CONCLUSIONS: Patients taking apixaban raised reasons for information-seeking about OTC products related to their perceptions of OTC products, provider-patient interactions, and their prior experiences with and frequency of OTC product use. Greater patient education about the need for information-seeking about potential DOAC-OTC product interactions may be needed at the time of prescribing.
Asunto(s)
Conducta en la Búsqueda de Información , Medicamentos sin Prescripción , Adulto , Humanos , Femenino , Masculino , Medicamentos sin Prescripción/efectos adversos , Aspirina , Pirazoles/efectos adversosRESUMEN
This paper conceptualizes the act of diagnosis in primary care as a 'diagnostic moment,' comprising a diagnostic utterance in a 'diagnostic slot,' together with a patient response. Using a dataset of 201 treated conditions drawn from 255 video recorded medical visits with 71 physicians across 33 clinical practices in the Western United States, we investigate the incidence of diagnostic moments, aspects of their verbal design, and patient responsiveness. We find that only 53% of treated conditions in the dataset are associated with a diagnostic moment. Physicians present 66% of these diagnoses as hedged or otherwise doubtful, and deliver 30% of them without gazing at the patient. In the context of these diagnostic moments, patients are non- or minimally responsive 59% of the time. These findings underscore the different significance that may be accorded diagnosis in primary care in contrast to care in other medical contexts. The paper concludes that the analysis of sequences of action which empirically realize diagnosis are underrepresented in the sociology of diagnosis, and that better understanding of the diagnostic moment would enhance our understanding of diagnostic processes in primary care.
Asunto(s)
Diagnóstico , Relaciones Médico-Paciente , Atención Primaria de Salud/métodos , Humanos , Atención Primaria de Salud/estadística & datos numéricos , Confianza/psicología , Incertidumbre , Estados UnidosRESUMEN
Using conversation analysis and a dataset of 171 video recordings of US primary care encounters (2003-2005), this paper examines patients' unsolicited pain informings - e.g. "that hurts" - during the physical examination phase of acute care visits. I argue that when patients experience pain in a physical exam but have not been asked a question like "does that hurt?", they face an interactional dilemma. Having presented their health problem to a doctor, they have tacitly set in motion epistemic and interactional asymmetries through which the doctor investigates the problem on their behalf. In this context, volunteering unsolicited pain information could facilitate progress towards an accurate diagnosis, but it could also be heard as independently asserting the relevance of pain to what the doctor is doing, thereby departing from the previously established asymmetries. I show that patients manage this dilemma by using turn design practices to implicitly account for unsolicited pain informings as motivated by a virtual solicitation and/or a sudden pain sensation. With these practices, patients manage to share potentially relevant pain information without accountably being heard to assert its relevance to the doctor's diagnostic inquiry. This achievement demonstrates how asymmetries in doctor-patient communication are a joint accomplishment of both doctors and patients, and are incarnate in the details of everyday clinical interactions.