Patients offer ‘unlikely’ explanations for their symptoms

1. Patients offer ‘unlikely’ explanations for their symptoms Anita Pomerantz Department of Communication University at Albany apom@albany.edu Summer Institute of Applied Linguistics Penn State University, July 2009

2. Contextualizing My Research 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 Patients offer ‘unlikely’ explanations - Pomerantz

3. Patient Resources Ask questions • Seek clarification Hint or ask for medical tests Hint or indirectly ask for medications Shape descriptions of their medical problems Patients offer ‘unlikely’ explanations - Pomerantz

4. 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 Patients offer ‘unlikely’ explanations - Pomerantz

5. Reasons for presenting ‘likely’ candidate explanations Display themselves as knowledgeable and involved in own care (Pomerantz and Rintel, 2004) Show problems are doctorable (Heritage and Robinson, 2006) Angle for particular treatment, e.g. antibiotics (Stivers, 2002) Patients offer ‘unlikely’ explanations - Pomerantz

6. 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. Patients offer ‘unlikely’ explanations - Pomerantz

7. Phases of the outpatient medical clinical visit Six phases (Heritage & Maynard, 2006) Opening Presenting complaint Examination Diagnosis Treatment Closing More general characterization of phases Physician collects data through verbal and/or physical exam • Physician analyzes data and presents findings (diagnosis) • Physician offers advice about treatment or management Patients offer ‘unlikely’ explanations - 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 Preference Organization Revisited - Pomerantz

9. 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. • Doctors treat patients’ minimal acknowledgments, continuers, and silence as alignment. • Aligning indicates willingness to move on. Patients may resist in outright fashion or suggest different diagnoses. Patients may resist tacitly by reporting symptoms and bodily states that are inconsistent with the diagnoses. • Resisting encourages delaying the progression of the visit. Patients offer ‘unlikely’ explanations - Pomerantz

10. 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. Patients offer ‘unlikely’ explanations - Pomerantz

11. But why do patients present unlikely candidate explanations? How do they function? Patients have different purposes for presenting different sorts of ‘unlikely’ candidate explanations. Explore what patients are doing when they raise benign or mundane candidate explanations and present evidence against those explanations Patients offer ‘unlikely’ explanations - Pomerantz

12. 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 Preference Organization Revisited - Pomerantz

13. 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. Preference Organization Revisited - Pomerantz

14. Preemptive Resistance Presenting 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. Preference Organization Revisited - Pomerantz

15. 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 Preference Organization Revisited - Pomerantz

16. Preference Organization Revisited - Pomerantz

17. Present benign candidate explanation and frame it as unlikely [18:1211 (25:27)] 1 Dr: U::m (.) let's see:. Couple of other things that 2 you've checked o:ff (0.7) .hh >you mentioned< 3 some::ah (1.5) ankle °swelling?° 4 Pt: Pch .h You know myfeet 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=an 9 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? ] Preference Organization Revisited - Pomerantz

18. Functions of arguing against benign candidate explanations • Patient implies candidate explanation is unlikely to be worthy of investigation. • Patient implies doctor should look elsewhere for diagnosis without going on record to promote serious options. • In implying rather than stating a serious option, patient can avoid possible attribution of jumping to worst case scenario. • Having considered and rejected commonplace explanation casts problem as puzzling and “doctorable (Heritage & Robinson, 2006). Preference Organization Revisited - Pomerantz

19. 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 • and suddenly I get them and they fall on me you know. • 33 .hhh(0.8) Think I gotta start using my umbrella or • 34 something. • 35 (4.5) • 36 Dr: .hh Kay, then the other:- the other thing you • 37 mentioned was:: (.) you have (.) pain with • 38 intercours:e.. Preference Organization Revisited - Pomerantz

20. 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. Preference Organization Revisited - Pomerantz

21. 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 Preference Organization Revisited - Pomerantz

22. Presenting serious candidate explanation as unlikely Intrigued by the following observations Patients seemed invested in raising candidate explanations while also invested in arguing against them. Patients often used elaborate packaging to present the ‘unlikely’ candidate explanation. There was ambiguity or minimization regarding their level of concern. Each patient succeeded, if not on the 1st try then on the 2nd, to direct the doctor’s attention to the candidate explanation. Preference Organization Revisited - Pomerantz

23. 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 Preference Organization Revisited - Pomerantz

24. Preference Organization Revisited - Pomerantz

25. 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 Preference Organization Revisited - Pomerantz

26. Patient describes the problem, offers ‘likely’ explanation 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) Preference Organization Revisited - Pomerantz

27. 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. Preference Organization Revisited - Pomerantz

28. Patient offers likely explanation, unlikely serious explanation, and unlikely benign explanation 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:ninna 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 Preference Organization Revisited - Pomerantz

29. 1st discourse features that reflect conflicting concerns 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? 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. Preference Organization Revisited - Pomerantz

30. 2nd discourse features that reflect conflicting concerns Patient provides her reasoning - but only tentatively. 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: Presenting self as able to reason about likelihood of appendicitis WHILE ALSO orienting to differential rights regarding medical expertise. Preference Organization Revisited - Pomerantz

31. 3rd discourse features that reflect conflicting concerns Patient portrayed appendicitis as unlikely, but did so with marked uncertainty. After no immediate response to “appendix,” patient ruled out benign explanation “a lot of gas.” Further presents unsolved puzzle. Portraying candidate explanation as unlikely while displaying uncertainty about it and puzzlement is a solution to conflicting concerns: Prompting the doctor to attend to that candidate explanation WHILE ALSO taking the stance that it is unlikely to be the case. Preference Organization Revisited - Pomerantz

32. 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. Preference Organization Revisited - Pomerantz

33. 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. Preference Organization Revisited - Pomerantz

34. Preference Organization Revisited - Pomerantz

35. 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 Preference Organization Revisited - Pomerantz

36. 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. Expressing concern way of re-introducing appendix such that doc would attend to that possibility. In reporting worries/concerns, used entitlement to know and report own feelings while respecting doc’s medical expertise, entitlements. Preference Organization Revisited - Pomerantz

37. 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. Preference Organization Revisited - Pomerantz

38. Concluding Remarks While doctors have rights to medical expertise and largely direct the consultation, patients also can have influence in the consultation. 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. With benign explanations, patients imply ‘Look elsewhere.” With serious explanations, patients seek reassurance that that isn’t the diagnosis. Preference Organization Revisited - Pomerantz

39. Implications for doctors 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. When patients attempt to further their agendas, more elaborate turn and sequence organization are needed. Patients need time to develop complex narratives and reports. 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. Preference Organization Revisited - Pomerantz

40. Patients offer ‘unlikely’ explanations for their symptoms Thank you Anita Pomerantz Department of Communication University at Albany apom@albany.edu Summer Institute of Applied Linguistics Penn State University, July 2009