s.ariss@sheffield.ac.uk

1. Asymmetric Claims to Knowledge in General Practice Consultations with Frequently Attending Patients Loughborough CA Day December 2011 Steven Ariss s.ariss@sheffield.ac.uk

2. Abstract: Participants in GP consultations display normative entitlements to knowledge related to their identities in the interaction. Claims of entitlement to knowledge are oriented to by the other participant as either straightforwardly acceptable or problematic. Thus asymmetry in doctor-patient interactions is collaboratively achieved (Drew, 1991; Gill, 1998). This paper seeks to describe a specific limitation on the participation of both parties regarding the discussion of patients’ problems, treatments and management of illness. Using Conversation Analysis this paper describes how the moral dimensions of epistemic authority constrain the different conversational resources available to GPs and patients and thereby result in the collaborative construction of asymmetry. Findings indicate that the types of talk necessary for reducing the asymmetry of epistemic authority in the medical consultation are routinely foregone in favour of efficient progression through the interaction. This has implications for health policy and practice guidelines aimed towards equal participation and shared understanding.

3. Background to the Study 23 consultations (4 GPs) Video recorded between November 2001 and November 2002 Frequent attenders (10 or more GP visits in previous 12 months) Age range 23 to 85 years (mean 52) males 21% (n=5), females 79% (n=18)

4. Overview • Characteristics of frequent attendance • Asymmetry: policy and guidance • Shared understanding, negotiation and agreement • Limitations of current approaches • Contribution of CA • Potential for reduced asymmetry

6. Frequent Attendance Equally frequent contact with other health professionals (Heywood et al, 1998) 93.9% (12 or more visits) have a chronic health problem (Heywood et al, 1998) Chronic physical presentations are characterised by asymmetry (voice of ‘lifeworld’/’medicine’) (Barry et al, 2001) More equal involvement is appropriate for chronic problems (‘mutual participation’) (Szasz & Hollender, 1956) More reliant on self-management

7. Asymmetry ofConsultations The ‘sick role’ (Parsons, 1951) Dominated by medical agenda (Byrne & Long, 1976) Bureaucratic format/etiquette (Strong, 1979) Voice of medicine/lifeworld (Mischler,1984) Disease/illness dichotomy (Kleinman, 1986)

8. Addressing Asymmetry

9. Patient-Centred Approach Equal importance of patient and professional perspectives More equal levels of participation Shift in the importance of topics From biomedical to patient’s opinions and experiences of illness “fundamental shift … in the balance between the biomedical and person centred aspects of individual care” (NSF Diabetes, 2001)

10. Partial Impact of Patient Centred Approaches Continuing professional dominance Limited extent of patient participation Continued emphasis on biomedical disease rather than experience of illness Failure to find ‘common ground’ Maintained separation of lay & professional perspectives (Barry et al, 2000; Coulter, 1997; Guadagnoli & Ward, 1998; Stevenson et al, 2000, Brown et al, 2003)

11. Common Ground & Shared Understanding

12. Finding Common Ground “research indicates how physicians still fail to find common ground with patients but at the same time reveals how finding common ground is important for both patients and physicians. Finding common ground may indeed be the linchpin of the patient-centred clinical method, thus further research on this component of the patient-centred clinical method is warranted”. Brown et al , Chapter 6 (p.85) in Stewart et al (eds), 2003

13. Finding common ground “the process through which the patient and doctor reach a mutual understanding and mutual agreement in three key areas: defining the problem; establishing the goals and priorities…; and identifying the roles” (Brown et al, 2003. p.83) Achieving shared understanding “Achieving a shared understanding: incorporating the patient’s perspective…to provide explanations and plans that relate to the patient’s perspective…to encourage an interaction rather than one-way transmission” (Silverman et al, 2005. p.24)

14. “The search for common ground should be an exchange and synthesis of meanings… Ideally, the exchange results in a synthesis of perspectives: they are after all, different perspectives – concrete or abstract – of the same reality.” (McWhinney, Chapter 2 in Stewart et al (eds), 2003. p.25)

15. Negotiation and Agreement

16. For Negotiation & Agreement: Physician: “Make or negotiate a decision in partnership with the patient and resolve conflict”. Patients: “Negotiate decisions, give feedback, resolve conflict, agree on an action plan” (Towle & Godolphin, 1999. Also see; Silverman et al, 2005; Charles et al, 1997 & 1999) Year Of Care for Diabetes (YOC)* “transforms the diabetes annual review… into a proper dialogue between the healthcare professional and the person with diabetes. They share information about their issues and concerns that includes clinical issues, the person’s experience of living with diabetes, and any other relevant information about what is going on in the person’s life. They then jointly agree the priorities or goals and what actions to take” (www.cgsupport.nhs.uk) *partnership initiative between the Department of Health, Diabetes UK, the Health Foundation and the National Diabetes Support Team

17. Against Negotiation, For Agreement: “Finding common ground requires that patients and physicians reach a mutual understanding and mutual agreement… Sometimes patients and doctors have divergent views…The process of finding a satisfactory resolution is not one of bargaining or negotiating but rather of moving towards a meeting of minds” Brown et al , Chapter 6 (p.96) in Stewart et al (eds), 2003.

18. For Negotiation, Against Agreement: “The …rationale for a negotiated approach …is …that conflict (disagreement) is an inevitable, common, normative part of clinician-patient relations” Lazare, ch4 in Lipkin et al (eds), 1995. p.62

19. Against Agreement: “the issue for concordance is not so much about patients and doctors reaching an agreement… but rather how conflicts over appropriate diagnosis and underlying explanatory schemas may be resolved” Pollock, 2005. p.58 i.e. Discussion of points of view (even if agreement cannot be reached)

20. Summary • Asymmetrical interactions are not considered good for patient care • Improved symmetry has proved hard to achieve • There is confusion about what symmetry should look like and how to bring about change • Interventions are based on idealised rational debate, rather than empirical understanding of social interactions

21. How Can CA Help? • Limitations of rational debate • Asymmetry of knowledge

22. Limitations of Rational Debate Garfinkel’s breaching experiments Strict rational discourse is an ideal which does not pertain to everyday conversation There are moral, socially sanctioned limits to the extent to which shared understanding should be pursued “For the purposes of conducting their everyday affairs persons refuse to permit each other to understand “what they are really talking about”” (Garfinkel,1967 p.41)

23. Limitations of Rational Debate Rational debate blocks conversation, whereas participants are normally motivated to progress steadily through a conversation rather than exploring differences(Antaki, 1994) Physicians used methods to speciously maintain “the outward appearance of negotiation and consensus, whilst minimising discussion of the patient’s symptoms” particularly when time pressure increased (Neustien, 1989)

24. Asymmetry of Knowledge • Asymmetry “is different from merely different states of knowledge”. • “Entitlements to knowledge are attached to…[speaker identities] – and not to persons…a speaker may posses some knowledge, but nevertheless have an asymmetrical position with respect to that knowledge”. • Speakers have normative entitlements to knowledge that are oriented to by themselves and their co-conversationalists as straightforwardly acceptable or in some way problematic. • (Drew, 1991 p.37)

25. Typical Asymmetrical Consultation [c.301] Dr: …that eye does look sore of yours doesn’t it (.) Pt: >Oh: he gave me?< (1.9) some stuff for er: what was it conjunctivitis? Dr: .hhtt’s not sticky in the mornings you said is it.= Pt: =It’s not now no. [it us]ed to be Dr: [right] Dr: Ri[::g h t ] Pt: [and then] I took that ointment and it er: (0.6) it worked out fine (0.5) Dr: .hh if it flares up over the next couple of days let me know cuz I don’t want you to have a bad eye for Christmas.

26. Potential for Symmetry Topics which are traditionally within the other’s realm of epistemic authority Patient discussion of: diagnoses, prognoses, test results, treatment options GP discussion of: patients’ experiences, circumstances and opinions of illness

27. Sequential Consequences of Non-Typical Orientations to Roles Speakers have normative entitlements to knowledge that are oriented to by themselves and their co-conversationalists as straightforwardly acceptable or in some way problematic. (Drew, 1991 p.37)

28. GP Responses to Patients’ Knowledge Claims

29. 2 common methods for patients to introduce medical knowledge or opinions 3rd party attributions Reference to their own experiences

30. GP Responses Non problematic Agreement Elaboration Problematic Lack of engagement Disagreement

31. Agreement 108:1 Pt: An I’ve got to: er:m (.) have (.) the lymphodaemia nurse look at this cuz it’s painful? Dr: Right . . . Pt: [ in ] the INFORMA:TION she’s given me Dr: Yeh (1.2) Pt: On lymphodaemia Dr: Right (2.0) Pt: A lot of the symptoms? (0.6)I can see, (.) I know I have got. Dr: Right Pt: Headaches, which I did(n)=know about because I’[ve been ] Dr: [I didn’t] know. that either? Pt: I’ve been in a lot of pain Dr: Ri:ght

32. Elaboration [108:2] Pt: a[ndih-] ih- it says in the notes= Dr: [hhhh. ] Pt: =that she’s sent methu- (0.7) Pt: ((cough)) that lymphodaemia if ifif I am diagnosed as having that Dr: Yehr Pt: You’ve got it for life (0.7) Pt: ac[cord[ing to the]= Dr: [TCK [ .h hh h] Pt: =information she sent me? Dr: It’s:: (0.6) this is a >very unusual type of lymphodaemia< (.)>lymphodaemia is usually people who’ve had radiotherapy< Pt: Mm=

33. Elaboration (continued) [108:2] cont. Pt: Mm= Dr: =uh- often for breast cancer and things like that [had] thuhr had thuhr the Pt: [Mmm] Dr: lymph glands interfered with up here in the arm. Pt: >Mm=hm< Dr: So that they no longer dr[ain] Pt: [mm ] >mm=hm<= Dr: =Er::m yours is a s:::- (1.1) Dr: ih uh totally different sort of lymphodaemia in as much as there- no specific damage to: (0.7) Dr: erm the lymph vessels or the lymph glands Pt: Right

34. Lack of Engagement [803] Pt: I KNOW NOWADAYS th[ey do TELL YOU NO]T to= Dr: [ I still think ] Pt: =do bed rest don’t they. (.) Pt: but I [have t]o say in all honesty unless= Dr: [ N o::] Pt: =I do h[ave som]e bed rest it’s no: Dr: [This is] (.) Pt: I can’t (.) walk Dr: Okay:. (0.6) I have given you back exercise chart before. Pt: Yeah Dr: I’ll like to give you (2.3) what are do’s and don’ts about the backpain (1.2) now what I would like also to do is to refer you (0.8) once AGAIN…

35. Non-Pursued Disagreement [106] Dr: ↑And I don’t want to see your blood pressure for six months, (.) I don’t wanna ↓know about it. Pt: Ohf::::. (h)ARE YUH SURE Dr: ABSOLU- >YE[S< absolutely fine.] Pt: [huh huh huh huh ]huh [huh ] Dr: [abso]lutely fine. .hh problem is if we do it too frequently then:: (0.5) Pt: It’[s:: not much ] difference [is the]re Dr: [yuhknow we end up] [ yehr ] Pt: Yuh[know] Dr: [or i]h- or:: yuhknow it’ll be up one time and down the nex[t un]d Pt: [yeah] (0.6) Dr: In all honesty just we end up chasing our tail if we change things too qui[ckl]y ] Pt: [yeh](h)]r [ hhhhh. ] Dr: [d’yuh need] any now::? (0.3) ↓any pills now.

36. Pursued Disagreement [803] Pt: Well my knee hur:ts cuz [uh=ah ah] feel as though= Dr: [ y e h ] Pt: =I’ve got arthritis in it but tha[t’s expec]ted at= Dr: [Y e s::] Dr: =my age isn’t it Dr: NO:? (0.5) it’s not an age. Pt: Oh(2.5) Dr: We do get wear and tear that does not mean(0.6) Pt: Ye:s:= Dr: =Somebody has [got arthri]tis: (1.0) Pt: [( )] Dr: Arthritis is a (0.4) illness wear a[nd tear is uh ] Pt: [WELL I KNOW I’VE GOT UH] BAKERS CY[ST.] Dr: [ Ok]ay= Pt: =Cuz I’ve had treatment for it Dr: That’s fine. Dr: Any trouble with the waterworks

37. Discussion of Differences Disagreement in consultations Usually indicated by lack of engagement Overt disagreement is quickly resolved without discussion of differences

38. Sequential Model for Avoiding Debate About Medical Opinions Patient transgresses role & compels a response  Doctor disagrees  Patient ‘retreats’ to entitled knowledge  Doctor abruptly changes topic or moves to next stage of the consultation

39. “The illusion of shared understanding” Patients already share the same views, or when views differ this is not conveyed. Thus allowing “patients to assume, incorrectly, that the doctors were confirming their own views” (Tuckett et al 1985 Meetings between experts , p.145)

40. Patient Responses to GPs’ Knowledge Claims

41. GP Discusses Patient Experience [108] Dr: Ah:r: but (0.5) the pain is at least bearable. (1.1) Dr: That's: (0.4) e(gh)[r on these painkillers] Pt: [ IT'S CONTROLLED BUT ] (.) Pt: I[F ] Dr: [ye]h Pt: If you look back through the records Dr: Y[eh ] Pt: [you]'ll see I've taken an awful lot of:? (1.0) Dr: Of the dihydr[ocod]eine yeh= Pt: ([sure]) Pt: =Dihydrocodeine and cocodamol Dr: Yeh (0.4) .hhh but you must watch cocodamol (0.4) they'r::e more than a little toxic…

42. GP Discusses Patient Experience [109] Dr: …we don’t see you every month just to say you’re still in pain you just get on with your life and you hav[e the pain so it’s not-] Pt: [ wull I’ll tell you-] I’ll tell you what it’s like yuhknuh- every morning when I get up I can’t move? (1.0) Pt: I a[m s:]o stiffened up and it’s all to= Dr: [yehr] Pt: =do with this now (.) Pt: In here:= Dr: =ºRightº (0.5) Dr: .h basic[ally what I]’ve said at the end here= Pt: [(and there)]?

43. Sequential Model for Avoiding Debate About Patient’s Experiences GPs discus patients’ experiences/ circumstances  Patient elaborates (competition for contiguous turn)  GP change of topic

44. Examples of Symmetry

45. Equal Knowledge Claims Pt: =Yeh er: what about thee=yer yuhknow that wheeze that I ‘ad. Dr: Oh ye[s : ] Pt: [ooh w]as real terrible ovver thuh weekend. Dr: (was it) Pt: And so yesterdee morning (.) I took six steroids. .hh and it shifted it (.) Dr: Ri::ght (.) but yuh jus[t took thuh six] Pt: [( )] is ah (.) ah just took six Dr: Have yuh got any more: steroids left? Pt: Oahr I’ve got plenty uh steroids left=y[es,] Dr: [rig]ht .hh I: would We[an] yourself Pt: [ah] Dr: o[ff quite quick[ly perhaps have ]four= Pt: [ I:: was [ >going tuh do that< ] Dr: =today and t[wo ] tomorrow and th[en ]stop= Pt: [yeh] [just-] Pt: =>that’s what ahr: was thinking meeself?< Dr: That’s fi[ne ] Pt: [doc]tor:. that’[s right] Dr: [well yo]u know your chest. that’s al[right. ] Pt: [yeh >th]at’s=right<

46. Equal Knowledge Claims [101] Dr: And I think we know that your [ E S ]R Pt: [( )] Pt: Mmm. Dr: Y[o u r E S [R was twenty six ]in September which= Pt: [it’s twenty [ s i x : : : ? ] Dr: =isn’t bad for you re[ally is it] Pt: [ N o : : ?] it is[n’t b a d.] Dr: [It’s been li]ke that fuh Pt: Oh ye[s :] Dr: [yea]rs really whether or- whether or: you- whether or no[t on the [STEROIDS] Pt: [These last [TWO BLOOD] TESTS have been twenty six.

47. Limitations & Opportunities for Equal Participation Potential for Symmetry Biomedical tests Pharmaceuticals/self-management (A. Pilnick, 1998) Persistent Asymmetry Definition of illness (GP) Experiences of illness (Patient) Personal Circumstances (Patient)

48. To find common ground or achieve shared understanding requires some form of rational debate Divergent knowledge claims limit the extent to which certain topics are discussed There is a strong preference for agreement in the talk so that conversation can continue, not necessarily because of agreement but despite conflicting views and attitudes

49. Asymmetry and Agreement The participant’s resources for claiming access to knowledge about the patient’s problem are quite different, and the outcome is that overt disagreement is unlikely to occur. Even if disagreement does occur (or looks likely), resolution is quickly established as both parties ‘retreat’ to their realms of epistemic authority.

50. Consensus on Moving Forward Vs Rational Debate Neither party is likely to pursue differences of opinion or potential areas of disagreement