A discourse-pragmatic analysis of shared decision-making

in physician consultations with older patients in Japan

Communication, Medicine and Ethics Conference 2020

Kayo KondoSchool of Politics, Philosophy, Language and Communication Studies

University of East Anglia

k.kondo@uea.ac.uk1

Outline

1) Shared Decision-Making (SDM)

2) SDM communicative process

3) Context with older patients – Cultural aspects

4) Face and Politeness research in medical encounters

5) Context of this study

6) Methods and Data

7) Analysis

8) Principal findings and Examples 1–5

9) Discussions and Implications

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Shared Decision-Making (SDM)

SDM as:• a collaborative process between clinicians and patients• working together to reach a mutual decision about a course of action or

treatment1. explains the problem2. discusses the treatment options as well as the risks and benefits of each3. explores the patient’s own preferences – ideas, concerns and expectations4. makes recommendations5. checks the patient’s understanding (Stiggelbout et al., 2012)

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SDM communicative process

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Main communicative elements adapted from the Calgary-Cambridge Guide (Silverman et al., 2013)

Sharing understanding

Sharing own

thinkingInvolving the patient

Context with older patients – Cultural aspects

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• High levels of involvement of family members as participants in SDM

ØA higher value is placed on family involvement or third party intervention in

SDM in Japan

• Lower desire to make their own treatment decisions (Taylor, 2009)

ØJapanese older patients feel comfortable with doctor-led decisions (Kuga et

al., 2016)

ØCultural communicative styles may be in conflict with the principle of SDM

Face and Politeness research in medical encounters

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• How verbal interaction in acts of SDM shapes face-work and interactional strategies:Øe.g. intimacy and sympathy are noticeably seen in ‘caring’ settingsØallows for comparisons of strategic choices related to the communicative acts

of SDMØdiscovers social and contextual variability

• Brown and Levinson’s (1987) politeness theory as an analytical framework• ‘face-work’, ‘face-threatening acts’• ‘negative/positive politeness strategies’ for addressing the patient’s

‘negative/positive face’

Face and Politeness research in medical encounters

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• Patient’s negative face as:‘the want to be unimpeded, and keep a psychological distance with the professionals, and the want to be treated politely by them’

• Patients’ positive face as:‘the want to be understood, empathised with and acclaimed by medical professionals, and the want to shorten the psychological distance with the professionals’

adapted from Brown and Levinson’s (1987) concept and Yoshioka’s work (Yoshioka et al., 2008; Yoshioka and Shin, 2010)

Context of this study

vCase study approach to face-to-face care for older patients in Japan

vAudio-recoded physician consultations at patients’ own homes

vParticipants: physicians and older patients (aged 65–99) and their family members where applicable

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Methods

How do doctors demonstrate a SDM approachwithin dyadic and triadic encounters?

vA participant-as-observer role in ethnographic fieldwork in TokyovAudio recordings and fieldnote taking in 28 cases

vExtract linguistic elements from transcribed and coded texts

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Gender Period of Practice Expertise Female 9 years Family physicianMale 10 years PsychiatristMale 12 years DiabetologistFemale 13 years Family physicianMale 14 years Family physicianMale 17 years Family physicianFemale more than 20 years Family physicianMale more than 20 years Family physician

Physician participants

Patient participants

Age group Female Male Total number

65-69 0 1 170-74 3 1 475-79 0 1 180-84 4 3 785-89 4 2 690-94 5 2 795-99 1 1 2

17 11 28

Data collected

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Consultations A Consultations BPlace of the consultations Patient’s own homes Patient’s own homesNature of the consultations Dyadic TriadicNumber of cases 14 cases in which patients were

on their own14 cases in which patients were accompanied by family members

The average duration of the full length of consultations

18.4 minutes 18.5 minutes

The period of the fieldwork was from January to June 2018.

Analysis

Qualitative and descriptive approach to the corpus:

1. Applying Jefferson transcription notation of conversation analysis

2. Coding to extract physician communicative acts in SDM adapted from the

Calgary-Cambridge Guide to a selected phase of SDM processes

3. Capturing the linguistic pragmatic notions of face-relevant strategies

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Principal findings

vA greater use of negative politeness – leaving more space rather than involving the patientØsoftening the offers, directivesØexpressions of hopefulnessØuse of inclusive formsØrespecting the patient’s wish to be independent

vMore explicit explanations when the families were present

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Category Instance Consultations A – Dyadic Consultations B – Triadic

Sharing understanding 13 6 7

Sharing own thinking 12 4 8

Involving the patient 6 3 3

Example 1 – Willingness to support the autonomy

• The doctor also applied positive politeness strategy by addressing the patient by his first name multiple times and showing his willingness to be supportive, as well as respecting the patient’s wish to be independent.

• The doctor paused frequently.

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Doctor

Doctor

This is my suggestion. (2.0) It will be easier for you to stay well and live longer if you keep the gastric tube, as it brings enough nutrition to the body. (3.0) It would be better to keep it. This is my opinion.

Since I first met you, I have tried to explain to you as many times as possible in person, and I have tried to choose the best option by consulting you, (2.0) not by talking to your son. I always want to know how you feel.

Example 2 – Use of inclusive forms

• The doctor sought a shared understanding on the use of antibiotics.• This hedging seems to be used strategically to minimise the communicative pressure on the patient.

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Doctor

PatientDoctor

PatientDoctor

if you plan to take [antibiotics], you should take it properly for the whole week, and, if you don’t plan to take it fully, you should take none at all. Meaning, either zero days or seven days is the way to do it, so,I was careless. […]Then, shall we try just water next time? If you don’t have a stomach-ache or any symptoms like that, just drink water even if you have blood in your urine, without taking antibiotics, shall we try that?I’ll try that.Let’s do it.

Example 3 – Softening the face threat in directives

• The doctor’s expressions softening the caution is specific; just as a statement of hopefulness, so that this advice did not sound too forceful and satisfied the patient’s wish to act as independently as possible.

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Doctor

Patient

Doctor

Patient

Doctor

Have you often fallen?

I try not to fall on my buttocks like before,

You fall skilfully. ((laugh)) ((Use of humour)) […]

I hope that you would not fall if possible…

After all, my feet do not touch the ground properly,

I hope that you make sure you’re standing properly on the ground with each step…

Example 4 – Reporting results to the family

• During the discussion, the patient was present but not directly involved.

• The doctor appeared to choose indirect expressions, so as not to worry the family, which led to little response from the family.

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Doctor

P-DaughterDoctorP-DaughterDoctor

Let’s say… as long as she takes care of it more carefully than a young person would, her kidney would be fine for the next 10 to 15 years…Right. I [understand.[Let’s think about the future after that at the right time.Right. I understand…Also, the indication for heart failure is marked ‘high’, but… if the indication is under 500, it is not particularly problematic…

Example 5 – Family involvement

• The patient’s husband and daughter believed that the patient should reduce or stop the intake of her tablets. It seemed obvious later that the patient still would take the tablets but she did not explicitly mention so. The doctor handled the situation by talking to the patient directly to confirm if it was acceptable with her.

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DoctorP-DaughterP-HusbandP-DaughterP-HusbandDoctorPatientDoctor

you can reduce or stop it (tablets). What would you like to do? ((asks to P))We’ll see her condition again, [and…[Let’s stop (taking the tablets) this time,Shall we [stop it?[Let’s see her condition.Let’s see how it goes…? ((asks to P))Yes.Then, let’s see and discuss again if we can stop or reduce… we’ll consider it.

Discussions

• Negative politeness strategies have been interpreted asØadopting an attitude of respect towards older patients rather than familiarityØ related to the cultural expectation of showing respect so as to reduce emotional discomfort for

the patient and their familyØ these personalised settings seemed to enable physicians to find redressive actions

• Influence of the presence of family membersØPhysician task priorities and sociability were flexible – more conversation of non-medical topicsØ tended to gain more information from the family than from the patient themselves, which could

influence the process towards a SDMØThe family’s sense of responsibility may reflect a general cultural tendency – a way of protecting

the patient from potential emotional suffering and pain caused by the sharing of bad news

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Implications

• Patient’s preference (about the level of desire to be involved; family involvement) vary considerably

Øindicates how important it is for physicians to act in conformity with patients’ expectations and understand their point of view

Øcan be taken into consideration when developing culture-specific consultation skills training

• The possibility that family involvement could result in the patient’s unwillingness to talk about their ideas and thoughts

ØPhysicians are expected to support the patient’s own decision-making capacity

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Conclusions

vThe principle aspects of SDM appeared to address the patient’s positive face;

however, SDM communicative acts were seen as attending the patients’ negative face

rather than positive face in actual practice in Japanese home settings.

vThe presence of family influenced the process towards a SDM.

vThe cultural diversity in SDM may vary considerably; Generalisations, therefore,

need to be carefully considered with regards to the interactional conventions of

particular cultures and settings.

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References

• Brown, P. & Levinson, S.C. (1987). Politeness: Some universals in language usage. Cambridge: Cambridge University Press.

• Kuga, S., Kachi, Y., Inoue, M. & Kawada, T. (2016). Characteristics of General Physicians who Practice Shared Decision Making: A Mail Survey of All Clinics in 12 Municipalities in Tokyo. Japan Primary Care Association 39(4): 209-213. [in Japanese].

• Silverman, J., Kurtz, S. & Draper, J. (2013). Skills for Communicating with Patients (3rd Ed.). London: Radcliffe Publishing.

• Stiggelbout, A.M., Van der Weijden, T., De Wit, M.P., Frosch, D., Legare, F., Montori, V.M., Trevena, L. & Elwyn, G. (2012). Shared decision making: really putting patients at the centre of healthcare. BMJ 344: e256.

• Taylor, K. (2009). Paternalism, participation and partnership—the evolution of patient centeredness in the consultation. Patient Education and Counseling 74 (2): 150-155.

• Yoshioka, Y. & Shin, S. (2010). Clinical Politeness Strategy for Appropriate Communications between Physicians and Patients. The Japanese Journal of Language in Society 13: 35-47 [in Japanese].

• Yoshioka, Y., Hayano, K., Tokuda, Y., Miura, J., Motomura, K., Aizawa, M., Tanaka, M. & Usami, M. (2008). Politeness strategy as an effective communication skill for improving the patient-physician relationship. Igaku Kyoiku (Medical Education) 39: 251-257 [in Japanese].

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