I recently reread this thoughtful article: “Conversation analysis: a method for research into interactions between patients and health-care professionals” (Drew, Chatwin, Collins 2001).

“Conversation analysis” is a central methodological framework that Ethnographic Solutions’ researchers use in their analysis of doctor-patient conversations.

In the late 1980s, conversation analysis emerged as a more formal field of inquiry in sociology.

Harvey Sacks, a founder of conversation analysis, was largely influenced by the renowned social psychologists Erving Goffman and Harold Garfinkel who wrote about the complex interpretive and presentational work that people do in the here-and-now of social interactions.

Goffman’s and Garfinkel’s schools of thought—known respectively as symbolic interactionism and ethnomethodology—also weigh heavily in our analysis of HCP-patient communications.

Garfinkel and Sacks were both professors of sociology at UCLA.  UCLA has since remained a leader in conversation analysis, drawing scholarship from both its sociology and anthropology departments.

Unlike traditional linguists who have been more concerned with language rules and etiquette, practitioners of conversation analysis view language as “talk in social interaction.” As Paul ten Have (2007) describes, conversation analysis is the “practice” of explicating how individuals—their methods and procedures—achieve and maintain interactional order in conversation (ten Have: 2007).

Certain analytic concepts and conversation “devices” figure prominently in conversation analysis, such as sequential organization, turn-taking / turn design, adjacency pairs, openings / closings, problem-solving, and repair devices.

Returning to the conversation analysis article on HCP-patient interactions, there are few points that I would like to explore.   In the article, they discuss another study by Heritage and Stivers (1999) in which they describe a conversation practice among doctors, which they call “online commentary” that occurs during the physical exam section of the physician-patient conversation.

“Online commentary” involves the doctor discussing (commenting, asking relevant questions) on the diagnostic significance of physical signs that they assess as they conduct the physical exam.

The researchers found that the online commentary is often oriented toward supporting the diagnosis and treatment plan to follow. Thus, the online commentary, they conclude, is an important conversation resource that doctors can use to secure patient buy-in—sometimes overcoming perceived patient resistance—to the doctor’s subsequent diagnosis and treatment plan.

Drew, Chatwin, and Collins (2001) then discuss another conversation analysis study of doctor-patient interactions in Finland conducted by Perakyla (1998).  This study pointed to how different physician approaches to sharing the evidentiary basis of a diagnosis had different impacts on patient conversation participation.

Doctors who discussed their physical exam findings out loud (e.g., online commentary) were effectively inviting patients to participate in the evidentiary basis of the diagnosis.  In other words, patients were encouraged to talk (i.e., given an implicit conversation turn) and provide additional information on their symptoms and experiences that supported or contradicted the doctor’s online commentary.

This contrasts with a different conversation format in which doctors presented their aggregated evidence at once—history, labs, radiography, physical exam—and then shared their diagnostic conclusion with the patient. The researchers in Finland found that this approach had the tendency to shut patients down—they were not encouraged to participate by sharing additional information on their case that they deemed relevant.

All this leads me to have a deeper appreciation of the physical exam section of the doctor-patient visit.

The physical exam, often positioned toward the end of the doctor-patient visit, does not typically last that long (e.g. generally less than 20% of the visit duration).  However, it is often the last section of physician data collection on the patient. Most of the time physicians and patients have previously discussed and reviewed the other key categories of evidence—history, labs, radiography, and findings from other physician visits.

The doctor is engaged in active synthetic work during the physical exam—weighing the evidence already collected, developing their working hypotheses, and using the last findings of the physical exam for confirmation.

In a way, the physical exam marks the start of the close of the physician-patient encounter. Patients are generally quiet during the physical exam. Uninvited comments—noise—could interfere with the doctor’s listening or focus. It is the doctor’s conversation turn—their right to talk.  If the doctor’s style is more interactive during the exam, it creates one last opportunity for the patient to participate and influence the imminent diagnosis and treatment plan.

Another thought provoked by the Drew, Chatwin, and Collins (2001) article relates to the idea of patients’ expectations going into the office visit. The article suggests that developing and educating HCPs on a set of communication “best practices,” by drawing insights from a corpus of conversation analyses on physician-patient interactions, could potentially enhance patient outcomes, like diagnostic accuracy, treatment adherence and patient satisfaction.

While it makes intuitive sense that these outcomes would improve by enhancing physician-patient communication, it is logistically complex to prove this—linking specific conversation approaches to enhanced patient outcomes at a large scale.

Perhaps one of the more practical ways to do this, they suggest, is with patient satisfaction surveys administered after the physician-patient conversation. They also suggest that an interview with the patient after their in-office visit with the doctor could help to reveal why the patient reports certain levels of satisfaction.

They seem to speculate that patient expectations—and whether later fulfilled or unfulfilled in the doctor visit—would factor into their reported satisfaction levels.

Here they indirectly acknowledge the shortcomings of a purely Conversation Analysis approach, which looks at doctor-patient conversations in excruciating detail, but does not consider the participants’ perspectives going into and following the encounter.

Conversation analysts often acknowledge that their interest is more in understanding how the participants sequentially structure their utterances in encounters and less about why they make those interactive choices. They assume that people are mostly driven in the conversation to achieve order, clarity, and agreement—signaling clearly, interpreting correctly, responding predictably, repairing misunderstandings, resolving problems, etc.

…but humans are more complex than that. There are a variety other factors—different motivations, perceptions, personal and treatment histories, expectations—that influence what they choose to discuss – or not discuss – in a medical encounter.

This is why our approach to physician-patient dialogue research extends beyond an isolated analysis of the doctor-patient conversation by having an on-site ethnographer interview the patient immediately before and after their in-office visit with the doctor.

Similarly, the ethnographer interviews the doctor at the start of the research day and then again at end of the day after their in-office visits with their patients have been observed.

The context gleaned from these interviews help in identifying key patterns in our subsequent conversation analysis of these in-office doctor-patient visits.

Written by Nicholas Kottak,  PhD

Nicholas Kottak, PhD is the President of Ethnographic Solutions, LLC.

Ethnographic Solutions is a leading ethnographic research company for pharmaceutical firms and healthcare companies.

Ethnographic Solutions offers a unique methodological and analytic approach to physician-patient dialogue research, day in the life patient ethnography, sales representative effectiveness research, and patient journey research.

References

Drew, P, Chatwin, J, Collins, S.  Conversation analysis: a method of research into interactions between patients and health-care professionals, 2001. Health Expectations. 4: 48-70.

Heritage, J, Stivers T. Online commentary in acute medical visits: a method of shaping patient expectations. Social Science and Medicine, 1999. 49: 1501-1507.

Perakyla A. Conversation Analysis: a new model of research in doctor-patient communication. Journal of the Royal Society of Medicine, 1997. 90: 205-208.

ten Have, P.  2007.  Doing Conversation Analysis.  2nd Ed. London. Sage Publications.