Offering patients choices: A pilot study of interactions in the seizure clinic

Abstract

Using Conversation Analysis (CA), we studied conversations between one UK-based epilepsy specialist and thirteen seizure patients in whom there was uncertainty about the diagnosis, and for whom different treatment and investigational options were being considered. In line with recent communication guidance, the specialist offered some form of choice to all patients: in eight cases, a course of action was proposed, to be accepted or rejected, and in the remaining five a "menu" of options was offered. Even when presenting a menu, the specialist sometimes conveyed his own preferences in how he described the options, and in some cases the menu was used for reasons other than offering choice (e.g. to address patient resistance). Close linguistic and interactional analysis of clinical encounters can show why doctors may feel they are offering choices when patients report that the decision was clinician-dominated.

Delivering patient choice in clinical practice: a conversation analytic study of communication practices used in neurology clinics to involve patients in decision-making

“…Moreover, the Finnish study, 41 discussed above, showed that unilateral decision deliveries themselves lie along a spectrum, both with respect to the extent to which they incorporate the patient's perspective and the extent to which they indicate that a response from the patient is relevant and expected. Our pilot study, 10 likewise, described a 'spectrum of openness' in relation to neurologists' practices for initiating decision-making. At the same time, as we have argued above, it is clear that patients have their own strategies for getting their voices heard.…”

Eliciting patient preferences in shared decision-making (SDM): Comparing conversation analysis and SDM measurements

“…In the first part (lines 1-5), the physician bolsters the rationale for his recommendation by presenting it as a joint decision of the whole medical team, based on "strong suspicion". This clearly tilts the response preference towards acceptance [8]. However, at this point he initiates a conditional clause conceding that the mother and the son may "think a bit differently" (lines [8][9]).…”

“…This clearly tilts the response preference towards acceptance [8]. However, at this point he initiates a conditional clause conceding that the mother and the son may "think a bit differently" (lines [8][9]). This does not frame such a stance as more or less legitimate, and thus rather neutrally provides for the possibility of an alternative preference.…”

“…Recently, a small body of conversation analytic studies has started to empirically specify how patient involvement and SDM actually play out in authentic encounters; For instance, how patients are offered choice [8][9][10] and how patient preferences are dealt with [11,12]. Our study develops this line of research further, by comparing conversation analysis (CA) with SDM measurements of the same data.…”

Do patients want choice? An observational study of neurology consultations

“…What is more, it demonstrates that it is not entirely straightforward for clinicians to provide patients with choice in a way that patients perceive as such. Preliminary qualitative work has provided some reasons why clinicians' and patients' views may diverge: for instance clinicians may use the "machinery" of choice (including a list of options followed by a question eliciting the patient's view) whilst heavily 'loading' the list and actually making a strong recommendation, rather than offering a choice between evenly 'balanced' alternatives [31].…”