Negotiating patient involvement in treatment decision making. A conversation analytic study of Norwegian hospital encounters

Abstract

This dissertation presents an examination of how physicians and patients make treatment decisions in actual encounters in a Norwegian hospital. The overall aim of the study is to identify and describe aspects of the interactional accomplishment of treatment decision making when patients are involved in the decision making, since current guidelines promote patient involvement in making decisions (i.e., shared decision making). The method used is conversation analysis (CA). Based on video recordings of actual interactions, CA is a datadriven approach for examining both how participants in talk accomplish actions and what interactional consequences those actions yield. Article 1 examines encounters where more than one option is brought up. Article 2 identifies one specific practice physicians use to bring up the patient’s stance towards treatment. Article 3 describes a physician’s strategies to secure a non-native speaking patient’s understanding and acceptance of an invasive treatment recommendation. In sum, this study shows how physicians and patients negotiate treatment decisions in at least three areas: (1) Firstly, the participants negotiate what treatment to choose. (2) Secondly, in order to arrive at a treatment decision, the participants negotiate the terms on which the decision should be made. These terms involve negotiating who will make the decision (deontic rights), which is dependent on determining on what grounds the decision should be based, either on the patient’s personal experiences and wishes (epistemics of experience), or on the physician’s medical expertise (epistemics of expertise). (3) Thirdly, negotiation may also concern determining which treatment options are available and appropriate (cf. the Patients’ Rights Act, § 3-1). The study shows that physicians and patients orient to, and indeed expect, a constrained form of patient involvement in decision making, where the physicians set important terms for opportunities and constraints for patient participation. The ways in which physicians involve patients (e.g., providing choice, bringing up patients’ views and securing patient acceptance) seem to curtail, rather than promote opportunities for patient involvement, in that the physicians’ actions primarily work towards bringing the patient ‘on board’ on decisions that correspond to the physician’s view. Nevertheless, patients also have ways of influencing decision making. Article 3 illustrates how a patient can even influence a decision through minimal participation, effectuated by an expectation of patients’ acceptance (or rejection) of treatment recommendations. This dissertation expands previous knowledge about how patients are actually involved in treatment decision making. Such fine-grained descriptions of authentic interaction may contribute to much needed empirical detail and specification that can be the basis for refining and developing recommendations for practice.