patients offer ‘unlikely’ explanations for their symptoms anita pomerantz department of...

Patients offer ‘unlikely’ explanations for their symptoms

Anita Pomerantz

Department of CommunicationUniversity at Albany

[email protected]

Summer Institute of Applied Linguistics Penn State University, July 2009

Contextualizing My Research

2Patients offer ‘unlikely’ explanations - Pomerantz

Growing body of CA research focuses on resources and practices that patients employ during clinic visits

Response to research that treated doctors as calling all of the shots

Aligned with movement for patient-centered practice

Patient Resources


Ask questions

Seek clarification

Hint or ask for medical tests

Hint or indirectly ask for medications

Shape descriptions of their medical problems

Patient Resource – Propose Candidate Explanation


Patients not only report on their symptoms; they share their reasoning about their symptoms. [How and why?}

Uncertainty markers display orientation to roles, differential rights

May explicitly state candidate explanation or imply it via symptom descriptions (Stivers, 2002, 2007)

Generally use formats that do not establish conditional relevance in next turn (Gill, 1995, 1998)

Generally present ‘likely’ candidate explanations, unless otherwise marked

Reasons for presenting ‘likely’ candidate explanations


Angle for particular treatment, e.g. antibiotics (Stivers, 2002)

Show problems are doctorable (Heritage and Robinson, 2006)

Display themselves as knowledgeable and involved in own care (Pomerantz and Rintel, 2004)

Relevance of Phases


Phases offer different opportunities for, and impose various constraints on, patients’ participation.

The ways in which patients present their candidate explanations of their illnesses are phase-specific.

The phase bears on what actions the patients do when they offer candidate explanations and the responses.

Phases of the outpatient medical clinical visit


Six phases (Heritage & Maynard, 2006)

Physician analyzes data and presents findings (diagnosis)

Opening

Presenting complaint

Examination

Diagnosis

Treatment

Closing

More general characterization of phases

Physician collects data through verbal and/or physical exam

Physician offers advice about treatment or management

Preference Organization Revisited - Pomerantz 8

First Study

Preemptive Resistance: Patients’ participation in diagnostic sense-making activities (Gill, Pomerantz, Denvir, in press)

Natural environment for resistance to diagnosis

Preemptiveness

Diagnostic Phase – Natural place for response to Dx


After doctor offers diagnosis, patient may align with, or resist, it.

Patient may align via agreeing assessment.

Patients may resist in outright fashion or suggest different diagnoses.

Resisting encourages delaying the progression of the visit.

Doctors treat patients’ minimal acknowledgments, continuers, and silence as alignment.

Patients may resist tacitly by reporting symptoms and bodily states that are inconsistent with the diagnoses.

Aligning indicates willingness to move on.

Data Collection Phase


Patients have opportunities to present their interpretations when they describe their medical problems.

Often they report explanations framed as likely or probable.

With likely explanations, patients can draw doctors’ attention to potential causes and hint, suggest, or forthrightly ask them to consider them during the visit.

But why do patients present unlikely candidate explanations? How do they function?


Explore what patients are doing when they raise benign or mundane candidate explanations and present evidence against those explanations

Patients have different purposes for presenting different sorts of ‘unlikely’ candidate explanations.


Data

Examined 50 consultations drawn from 3 data sets:

Late 1980s internal medicine clinic in Midwestern teaching hospital

Early 1990s in ambulatory clinic in teaching hospital in large Eastern city

Early 2000 in a family practice clinic located in a mid-sized Eastern city


Methods

Conversation Analysis

Examined recordings of medical visits along with detailed transcripts

Analyzed how persons employ shared interactional resources to accomplish social actions and activities.


Preemptive ResistancePresenting benign candidate explanation, then casting it as unlikely

In information gathering phase, patient talks about a problem or symptom and raises a candidate explanation (X)

Patient resists candidate explanation by providing evidence that X is not the cause or by suggesting there is no evidence to support X as the cause.

Optionally, the patient also may add an upshot that explicitly rules out X.


Example - offer benign explanation, frame as unlikely

Patient describes feet swelling as a medical problem

Patient introduces summer heat as a candidate explanation

Patient offers evidence against summer heat as a likely explanation


Present benign candidate explanation and frame it as unlikely

[18:1211 (25:27)] 1 Dr: U::m (.) let's see:. Couple of other things that2 you've checked o:ff (0.7) .hh >you mentioned<3 some::ah (1.5) ankle °swelling?°4 Pt: Pch .h You know my feet never used to swell at all.5 In fact that was one of the things I always got iv:-6 (0.2) was admired by everybody.=How come you can take 7 your shoes o(h)ff and you(h)r feet never swell. .HH 8 You know. .hh And the la:st couple of months=an9 course it's summer.[An it's] °hot.°[.hhh] You know:. 10 Dr: [M hm ] [M hm]11 Pt: A::hw (.) but my FEET have swelled. 12 And I:[N:: ]E:Ver °had that b[efore.°]13 Dr: [M hm] [M hm? ]


Functions of arguing against benign candidate explanations

Patient implies candidate explanation is unlikely to be worthy of investigation.

Having considered and rejected commonplace explanation casts problem as puzzling and “doctorable (Heritage & Robinson, 2006).

In implying rather than stating a serious option, patient can avoid possible attribution of jumping to worst case scenario.

Patient implies doctor should look elsewhere for diagnosis without going on record to promote serious options.


Doctor’s reaction to summer heat as unlikely cause

[18:1211 (25:27)] Continued 28 Dr: Does it seem like everything is catching up with you?29 Pt: Ye::ah.30 Dr: hhhh ((Doctor is smiling.))31 Pt: All the things that people have had all these years 32 and suddenly I get them and they fall on me you know.33 .hhh(0.8) Think I gotta start using my umbrella or34 something.35 (4.5)36 Dr: .hh Kay, then the other:- the other thing you37 mentioned was:: (.) you have (.) pain with 38 intercours:e..


Preemptively arguing against benign candidate explanation

Patients raise and resist candidate explanations in advance of diagnostic informing, when doctors still are gathering information

In this early phase, patient offer descriptions of problem together with his/her sense of what is not causing the problem to occur.

Location and format allows doctor to continue the medical work-up in light of the evidence patient provided rather than to respond immediately.

Potential problem: when doctor continues to gather information, it may not be transparent whether contribution influenced the trajectory of the inquiry.


Second Study

When patients present serious health conditions as unlikely: managing potentially conflicting issues and constraints (Pomerantz, Gill, Denvir, 2007)

Discourse reflects conflicting issues and constraints


Presenting serious candidate explanation as unlikely

Patients seemed invested in raising candidate explanations while also invested in arguing against them.

Intrigued by the following observations

There was ambiguity or minimization regarding their level of concern.

Patients often used elaborate packaging to present the ‘unlikely’ candidate explanation.

Each patient succeeded, if not on the 1st try then on the 2nd, to direct the doctor’s attention to the candidate explanation.


Overview of Excerpt

Patient describes medical problems

Patient raises “bladder infection” as a candidate explanation

Patient raises “appendix” as a candidate explanation

Patient raises “a lot of gas” as a candidate explanation


Adding to the overview of excerpt

Patient describes medical problems

Patient offers bladder infection as likely candidate explanation not serious, likely

Patient offers appendicitis as a serious candidate explanation, and presents evidence against it serious, unlikely

Patient offers a lot of gas as a benign candidate explanation, and presents evidence against it benign, unlikely


Doc: Uh why- wh:y are you um at the clinic today=what seems to be the [problem.]

Pt: [(W’ll) I] ha- I have this pressure in my uh lowuh stomach, (1.0) Pt: And uh: slightly (stiff) I cain’t (0.7) you know (.) (hardly-) can’t hardly walk like I shou:ld. Doc: Mm hmm, Pt: You know, (1.0) Pt: When I go to ba:throom (um) uh (1.7) it’s u:h (1.5) (like) stings a little, Doc: Mm [ hmm ] Pt: [(And uh)] (1.0) it may be a bladder condition=I’ve had dat before, Doc: You’ve had that bef- (tha]t’s)

Patient describes the problem, offers ‘likely’ explanation


How the patient created an opportunity to raise candidate explanations

Early phase of visit, in slot provided by doctor’s soliciting reason for visit

Described symptom (pressure), indicated its severity, then offered another symptom commonly associated with bladder infection

In that environment, she offered “bladder condition” as 1st of several candidate explanations.


Pt: (And uh)](1.0) it may be a bladder condition=I’ve had dat before, Doc: You’ve had that [bef- (tha]t’s) Pt: [An’ then] (0.7) I thought it was my appe:ndix=I don’t know I d- guess (I) wouldna’ la:st this long=I woulda’ h- had (0.2) woulda’ had tuh be here before now. (0.2) Pt: I don’ know=an’ den .hh I hadda’ lot of ga::s. Doc: Mm [hmm] Pt: [You] know but it (0.2) seem to be die:in’ down=but uh- I still have this pai:n inna lower s:tomach. Doc: Right. Pt: And y’ see here you see how I be walkin’ Doc: Mm h[mm] Pt: [ H]mm .hh (.) Pt: An’ u:m den I had uh pains in my chest

Patient offers likely explanation, unlikely serious explanation, and unlikely benign explanation


1st discourse features that reflect conflicting concerns

Presenting multiple candidate explanations, with the serious one in non-initial position, is potential solution to conflicting concerns:

Raising appendix as a possibility for doctor’s consideration WHILE ALSO presenting self as person who does not embrace worst case scenario.

Before raising appendicitis as possibility, patient presents bladder condition as likely possibility.

What if she had presented appendicitis as her first or only candidate explanation?


2nd discourse features that reflect conflicting concerns

Patient provides her reasoning - but only tentatively.

Presenting self as able to reason about likelihood of appendicitis WHILE ALSO orienting to differential rights regarding medical expertise.

An’ then] (0.7) I thought it was my appe:ndix=I don’t know I d- guess (I) wouldna’ la:st this long=I woulda’ h- had (0.2) woulda’ had tuh be here before now. (0.2) I don’ know

Presenting patient’s medical reasoning with uncertainty markers is a solution to conflicting concerns:


3rd discourse features that reflect conflicting concerns

Patient portrayed appendicitis as unlikely, but did so with marked uncertainty.

Prompting the doctor to attend to that candidate explanation WHILE ALSO taking the stance that it is unlikely to be the case.

Portraying candidate explanation as unlikely while displaying uncertainty about it and puzzlement is a solution to conflicting concerns:

After no immediate response to “appendix,” patient ruled out benign explanation “a lot of gas.” Further presents unsolved puzzle.


Doctor’s responses to candidate explanations

Doctor acknowledged 2 of the 3 candidate explanations

Bladder condition: “You’ve had that bef- (that’s)”

Lot of gas: “Mm hmm” and “Right”

With no acknowledgement of appendix talk, patient would not know whether or not doctor would attend to it as a possible diagnosis.


2nd presentation of appendicitis as candidate explanation

Patient created an opportunity to re-raise appendix

When doc was moving to close questioning about possible bladder infection and start questioning about her chest pain, patient jumped in, with no gap, to again raise appendicitis.


Doc: .hh U:h (0.2) any burning when you urinate? ` (1.0) Pt: M:aybe a little ( )

(1.0) Pt: Maybe ( ) (0.2) I don’ know.

(0.5) Pt: until I (1.0) (s’posed to) u:rinate in a cup like [an’ ] ‘en they take the [uh] Doc: [Yeah] [Ye]ah I- I’ll take a look at your urine i- in a little bit and we’ll see if that’s what’s (.) what’s goin’ on= Pt: =I jus’ hope it wasn’t no appendix. Doc: Okay.= Pt: =Was what I was worried [about. ] Doc: [Tha- th]at seems to be your major concern whether (.) whether it’s [an appendix.] Pt: [( ] ) Doc: [Yeah] Pt: [An’ I] had uh (0.2) cesarian (.) too= Doc: =Mm hmm Pt: With eight children Doc: Okay (.) well we’ll- we’ll sort it out when I examine you we’ll see uh (.) u:h (0.5) i- if that’s a possibility


Patient re-raised candidate explanation while orienting to conflicting concerns

1st occasion patient framed appendicitis as ‘improbable.’ On 2nd occasion, she expressed emotions of concern and worry (past and present tense)

“I jus’ hope it wasn’t no appendix”“Was what I was worried about”Confirms that her “major concern” is whether it was appendix.

In reporting worries/concerns, used entitlement to know and report own feelings while respecting doc’s medical expertise, entitlements.

Expressing concern way of re-introducing appendix such that doc would attend to that possibility.


Doctor’s response to candidate explanation

Inasmuch as doctors direct their attention to patients’ stated worries, their expression should succeed in directing the doctors’ attention.

In diagnostic phase, doctor referred back to patient’s concern, gave multiple reasons for ruling out appendicitis, reassured patient to not worry.

Likely the extent to which he reassured patient was a response to patient’ invoking worry to reinteroduce appendix.


Concluding Remarks

By raising and ruling out benign candidate explanations, patients may direct doctors attention to more serious possibilities without going on-record to articulate them.

By raising a serious candidate explanation and presenting evidence against it, patients may direct doctors’ to address those possibilities while presenting themselves as knowledgeable and reasonable.

While doctors have rights to medical expertise and largely direct the consultation, patients also can have influence in the consultation.

With benign explanations, patients imply ‘Look elsewhere.” With serious explanations, patients seek reassurance that that isn’t the diagnosis.


Implications for doctors

When patients attempt to further their agendas, more elaborate turn and sequence organization are needed. Patients need time to develop complex narratives and reports.

Difficult to interpret whether patient currently is concerned or not, and whether to address something that sounds like its ruled out. Framing may be shaped for interactional considerations.

Patient have resources to express their interests, often indirectly. Also although it takes more interactional work, they have resources to pursue when their interests are not heard on a first occasion.

Patients offer ‘unlikely’ explanations for their symptoms

Anita Pomerantz

Department of CommunicationUniversity at Albany

[email protected]

Summer Institute of Applied Linguistics Penn State University, July 2009

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patients offer ‘unlikely’ explanations for their symptoms anita pomerantz department of...

Documents

patients participation

medical problems patients

state candidate explanation

medical testshint

care pomerantz

phase bears

symptom descriptions

particular treatment