Tijdschrift voor Taalbeheersing - Volume 43, Issue 2, 2021

The empirical papers in this special issue show that how knowledge is made relevant and negotiated in interaction is a complex matter. Traditionally, research on knowledge conceptualizes knowledge as being distributed across patients and health care providers, who respectively have access to experiential knowledge and medical knowledge of illness. In this view, both forms of knowledge then need to be transferred from one party to the other. However, our contributions show that interactions are more complex in many ways. First of all, there are more actors involved in medical interaction, such as translators and family members, who each uniquely contribute to what knowledge is constructed and how. Secondly, the forms and domains of knowledge cannot be reduced to medical and experiential knowledge, but for instance also concern knowledge on how health care interactions are structured. Thirdly, knowledge is not only about informing the other party in interaction but is for instance also used to account for decisions or to seek alignment. In this contribution we explore how these insights can inform future research and how it can help deepen our understanding of patient centredness and shared decision making in health care communication.

Well begun is half done. Deontic and epistemic authority in the opening phase of medical consultations

Context: An effective consultation opening with attention to patient participation not only increases patient satisfaction, but is also a prerequisite for shared decision making, which may improve health outcomes and reduce healthcare costs.

Methods: Using conversation analysis, we examined linguistic and structural characteristics of 41 video recorded consultation openings of medical specialists at a large Dutch teaching hospital. The main purpose was to give an overview of how doctors and patients interactionally shape deontic and epistemic authority.

Results: Conversation analysis showed different ways in which doctors open their consultations and patients’ reactions to this. Agenda setting occurred in 6 cases, this was always the doctor’s agenda. Most of the doctors’ utterances during this phase displayed a high deontic stance and none of the patients were invited to discuss their expectations or goals for the consultation. 30 doctors started with their opening question, which in itself also reflects a high deontic stance. During the opening questions, the doctors’ epistemic stances differed.

Conclusion: During the consultation openings, the doctor was clearly in charge of the conversation and often did not explore the knowledge domain of the patient. This can limit patient participation and can hinder shared decision making in the consultation.

Misconception and contraception: knowledge and decision-making in contraceptive consultations with a language barrier

Just like in general medical consultations, different domains of knowledge come together and are negotiated in contraceptive consultations, followed by decision-making on the contraceptive method. Research shows that a language barrier can hamper knowledge negotiation and decision-making in medical consultations. Our paper contributes to those findings by focussing on contraceptive counselling as a specific and underexplored consultation type. We gathered our data in a Belgian abortion clinic, where contraception is discussed during the consultations, and where an important part of the consultations are characterised by a language barrier. We adopt a Bourdieusian view on language as capital, and use a linguistic ethnographic and interactional sociolinguistic approach, complemented with analytical tools from conversation analysis on epistemics and deontics. The analysis of data fragments, ranging from a limited to a double language barrier, shows that this barrier is connected in various ways with how, and how much, knowledge is negotiated. Incomplete renditions, interruptions, epistemic and deontic claims from non-professional interpreters, along with a lack of shared contextualisation, impede clients to gather information and therefore influence decision-making. We conclude that a language barrier involves a potential risk for knowledge negotiation and decision-making in contraceptive consultations. More attention from healthcare professionals to language barriers could empower women in their sexual and reproductive health choices.

Regelmatig nemen patiënten een begeleider mee naar medische consulten. Het verloop van shared decision making (SDM) in consulten met drie partijen heeft tot nu toe echter weinig aandacht gekregen. In deze studie wordt nagegaan welke invloed de derde partij kan hebben op het beslisproces. Daartoe specificeren we de rollen die deze partij op zich kan nemen en bespreken we, vanuit een pragma-dialectisch perspectief, hoe deze rollen zich vertalen naar rollen binnen een discussie. Tot slot zetten we op basis van voorbeelden uiteen hoe deze rollen tot uiting kunnen komen in het besluitvormingsproces.

In een consult met drie partijen blijken vanuit argumentatief oogpunt twaalf complexe discussiesituaties te kunnen ontstaan, afhankelijk van de aard van het geschil, eventuele coalitievorming en de rollen die de partijen op zich nemen. In een aantal discussiesituaties kan de derde partij een actieve rol spelen en zodoende deelnemen aan het besluitvormingsproces. Alle drie partijen kunnen daarnaast anderen bij de discussie betrekken (bijvoorbeeld door hun mening te vragen) of een coalitie suggereren (bijvoorbeeld door in de wij-vorm te spreken).

Indien een derde partij een coalitie suggereert, kan dit enerzijds SDM ten goede komen, doordat de begeleider de patiënt in het besluitvormingsproces steunt. Anderzijds kan dit ook het besluitvormingsproces bemoeilijken wanneer de derde partij (bewust of onbewust) ten onrechte namens de patiënt spreekt. Op eenzelfde wijze kan een derde partij meer of minder constructieve bijdragen leveren aan de besluitvorming door standpunten of argumenten te baseren op de eigen (vermeende) expertise.

Abstract

The third party in shared decision making. The role of extra participants in discussions between health professionals and patients

Patients often bring along a companion to medical consultations, which ideally involve shared decision making (SDM). The way in which SDM proceeds in consultations with three parties has, nonetheless, so far received little attention. In this study, we analyse how the presence of a third party can affect the decision making process. To do so, we specify the roles that this party can fulfil, and discuss, using the pragma-dialectical framework, how these roles relate to discussion roles. Lastly, based on a qualitative analysis of a number of examples we illustrate how the roles that a third party could fulfil can be expressed in actual medical decision making.

From an argumentative perspective, twelve complex discussion situations could arise from the presence of three parties, depending on the nature of the disagreement, possible coalition building, and the roles that the parties fulfil. In a number of discussion situations, the third party can play an active role and thus take part in the decision making process itself. All three parties could additionally invite others to participate in the discussion (for instance, by asking for their opinion) or suggest that a coalition has been formed (for instance, by using inclusive ‘we’).

A third party suggesting that a coalition exists can further SDM, as the companion could thereby support the patient in the decision making process. However, this could also hinder the decision making process if the third party (consciously or unconsciously) unjustifiably speaks on behalf of the patient. In a similar vein, a third party could contribute in a more constructive or less constructive manner to the decision making process by basing standpoints or arguments on their own (supposed) expertise.

On the discursive construction of emotional problems in head-and-neck cancer follow-up consultations

Cancer survivors often experience heightened emotional distress, resulting in reduced quality of life. However, previous research has shown that oncologists tend to avoid discussing emotional issues with these patients. In this paper we analyse doctor-patient interaction in follow-up head-and-neck cancer consultations in a major cancer centre in The Netherlands, comparing data from a Control group and a group that used the Distress Thermometer and Problem List (DT+PL) to stimulate the discussion of emotional concerns. We found that, although emotional problems were addressed in both conditions, the change in the doctors’ epistemic status occasioned by the DT+PL caused there to be a marked difference in who first nominated the concerns as topics. When and how which issues were discussed was mutually, discursively, negotiated by the participants in the situation. Doctors were seen to rely in these negotiations on their bio-medical knowledge, while patients and companions used their own lived experience and the experiences of third parties. Detailed analysis of the data shows that when there was a disjunct between the knowledge that patients and doctors relied upon, both doctors and patients were very diffident when expressing disagreement.

“We agreed to….”: how do health care professionals account for their performance in reports?

For many health care professionals, reporting is a daily, necessary task. Reports play a key role in the accountability practice of the care provided, like quality assurance, evaluation, coordination and continuity of health care. However, to write an efficient report in the Electronic Client Dossier (ECD) is not an easy task for professionals. Research illuminates that health care reports do not meet the required quality level, stressing the importance to address writing skills of these professionals.

In this study, consisting of 50 health reports of two mental health care organizations, we explore accountability practices of health care providers in reports. The analysis demonstrates how professionals actively give accounts for their performance at two levels, namely (1) the interaction: accounts for the accomplishment of mutual understanding and the unfolding of the institutional conversation and (2) the care content: accounts for the directions of the health care process and/or future steps. These practices of ‘being accountable’ illuminate how the writing process of professionals is embedded in the institutional context of health care. Therefore, to improve the efficiency and quality of reports, it is crucial to train the strategic competence of professionals instead of just training writing skills.

Kijksluiters: watching conversations between pharmacists and patients

As of 1975, Dutch patients receive a package insert with their medication. Due to extensive national and EU legal regulation efforts, the insert developed into a mandatory genre par excellence. However, its communicative functionality remained doubtful: the patient information leaflet has always been regarded as lengthy, complex and user-unfriendly. Recently, the Dutch Medicine Board has introduced a new, audiovisual medication instruction, the so-called Kijksluiter, that shows a video animation of a conversation about the medicine between a pharmacist and a patient. After a historical introduction, the second section of the paper surveys empirical studies that shed light on the main design parameters of the new genre: spoken instead of written information, animated speakers, dialogue instead of monologue. In the third part, we report on an observation study in which 16 users answer 9 scenario questions using a Kijksluiter video. The results indicate that Kijksluiters are not without user problems. Overall, two-thirds of the answers are more or less correct. Half of the participants first watched the video in its entirety before attending to the questions. The main problem this group encountered is: insufficient recollection of the relevant information. The other half of the participants navigated the Kijksluiter for each question, using the menu offering twelve small chapters. The main problems in this group was not finding the question-relevant chapter; but even after listening to the relevant information, some answers are incorrect. We conclude that, although Kijksluiter does not immediately solve all medication communication problems, its concise audiovisual format broadens the range of media available for medicine users.