David Butt

Developing ethical strategies to assist oncologists in seeking informed consent to cancer clinical trials

Randomised clinical trials have come to be regarded as the gold standard in treatment evaluation. However, many doctors see the discussion of a clinical trial as an intrusion into the doctor-patient relationship and find these discussions difficult to initiate. Detailed informed consent is now a requirement of patient participation in trials; however, it is known that patients commonly fail to understand and recall the information conveyed. These difficulties for doctors and patients raise questions about the ethical integrity of the informed consent process. In this study, we have developed a set of communication strategies underpinned by ethical, linguistic and psychological theory, designed to assist doctors in this difficult task. Initially, audiotape transcripts of 26 consultations in which 10 medical oncologists invited patients to participate in clinical trials were analysed by expert ethicists, linguists, oncologists and psychologists, using rigorous qualitative methodology. A subset of seven of these was subjected to detailed linguistic analysis. A strategies document was developed to address themes which emerged from these analyses. This document was presented to relevant expert stakeholders. Their feedback was incorporated into the final document. Four themes emerged from the analysis; (a) shared decision-making, (b) the sequence of moves in the consultation, (c) the type and clarity of the information provided and (d) disclosure of controversial information and coercion. Detailed strategies were developed to assist doctors to communicate in these areas. We have developed a set of ethical strategies which may assist health professionals in this difficult area. A training package based on these strategies is currently being evaluated in a multi-centre randomised controlled trial.

Grammar–The First Covert Operation of War

The cultural perturbations created by 11 September (9/11) have produced a layering of discourses. These layers offer a remarkable opportunity for interpreting ideology in relation to text construction. We examine two degrees of this textual dispersion: first, the motivated selection in the crafting of President Bush’s first speech after 9/11; and second, the speech by British Lieutenant Colonel Tim Collins as he exhorts his troops before engagement in the war against Iraq of 2003. The texts are remarkable for their similarities and their differences – two different contexts in which humans are called to enact policy which involves behaviour that should be abhorrent. Bush presents an asymmetrical world (in moral, not economic, terms); and this asymmetry is mainly expressed in the consistent allocation of grammatical roles. Collins presents the regiment’s task as a family mission, with dramatic switching between positive constructions of an Old Testament Iraq and the regiment (‘family’) on the one hand, and the ‘rightful destruction’ of the enemy, on the other hand. Again, but in more varied ways, it is the grammar which carries the burden of discriminating between those to be protected and those to be targeted. Ideology in language follows from the fact that we can construct multiple versions of the ‘same’ physical, biological, social and semiotic events.

Development of a communication aid to facilitate risk communication in consultations with unaffected women from high risk breast cancer families: A pilot study.

The literature on risk perception in women from high-risk breast cancer families reveals persistent over-estimation of risk, even after counseling. In this study, a communication aid was designed to facilitate discussion of risk between clinical geneticists and genetic counselors and women from this high-risk population. Method: Stage 1. The aid was developed by an expert panel of clinical geneticists, genetic counselors, psychologists, an epidemiologist, an oncologist, linguists and a consumer. It was guided by the international literature on risk communication and a large multi-centre Australian study of risk communication. The 13 page full-color communication aid used varying formats of words, numbers, graphs and pie-charts to address (a) the woman’s subjective risk; (b) the population risk of breast cancer; c) the risk of inherited breast cancer; (d) the cumulative risk for women with BRCA1 and BRCA2 mutations; (e) family risk factors; (f) the woman’s suitability for genetic testing; (h) screening and management recommendations, and (i) a re-assessment of the woman’s subjective risk. Stage 2: A before–after pilot study of 38 women who were unaffected with breast cancer and were attending four Australian familial cancer clinics was undertaken. Baseline and follow-up questionnaires were completed by 27 women. Outcomes were compared to those observed in 107 similar women undergoing genetic counseling without the communication aid in 2001. Results: The risk communication aid appears to be beneficial; breast cancer genetics knowledge improved in some areas and importantly, risk perceptions improved in the cohort receiving the communication aid. Psychological measures showed no difference in anxiety or depression between the group receiving the communication aid and the comparison cohort. Women and clinicians were very positive about the usefulness of the communication aid as an adjunct to the genetic counseling consultation.

Linguistic analysis of verbal and non-verbal communication in the operating room

Surgery can be a triumph of co‐operation, the procedure evolving as a result of joint action between multiple participants. The communication that mediates the joint action of surgery is conveyed by verbal but particularly by non‐verbal signals. Competing priorities superimposed by surgical learning must also be negotiated within this context and this paper draws on techniques of systemic functional linguistics to observe and analyse the flow of information during such a phase of surgery.

A Poetics of change

The progress of psychoanalysis and psychotherapy depends on our capacity to study, in a scientific manner, the process of therapy. Since a study of this kind involves charting the waxing and waning of something as elusive as the sense of personal existence, the task has, in the past, been seen as virtually impossible. However, words, or more particularly, the way words are used, manifest such shifting states. Sophisticated linguistic analyses are available, providing the means to conduct these necessary studies. This article suggests that an ongoing sense of personal existence, which William James called “self,” is multilayered, in the manner of the poetic, and that indices of such layering will reflect beneficial change. The description of this zone of experience, which might be called the synchronic, depends on contributions from Marcel Proust, Virginia Woolf, Henri Bergson, and Ferdinand de Saussure. An illustration of the value of a consideration of the minute particulars of the therapeutic conversation is given by means of extracts from therapy sessions seven months apart.

Formulation, conversation and therapeutic engagement

Objectives: The aim of this study was to review psychodynamic formulation with respect to the language used and the evidence it provides about variations of clinical purpose. Method: The purpose of the psychodynamic formulation is considered in training and clinical contexts. Three formulations are presented: two written from alternative theoretical perspectives and one designed to be spoken to the patient. Linguistic comparisons are made using these examples, emphasizing differences in grammatical complexity, lexical density (‘wordiness’) and other qualities. Results: The essential purpose of psychodynamic formulation is to develop an understanding that can be shared in the service of effective care. Significant differences were found between written and spoken versions with greater grammatical complexity and lower lexical density in the spoken form. An intrapsychic theoretical model was more grammatically complex and ‘noun-based’ compared to an inter-subjective model. Other differences are also described, including the tendency for the intrapsychic account to efface the sense of personal agency. This contributes to the impression of a subject under the influence of ‘unseen’ forces. Conclusions: The communicability of psychodynamic formulation is essential to its utility in clinical practice.

The impact of the medical emergency team on the resuscitation practice of critical care nurses

Background Medical Emergency Teams (MET)/rapid response are replacing Cardiac Arrest teams in acute hospitals. There is a lack of knowledge about how Critical Care Nurses (CCNs), rostered on MET construct their responsibilities/roles. Objective Assess MET nurse activities at different hospitals. Methods The authors used visual ethnography; selecting Systemic Functional Grammar as our methodological framework. The Generic Systemic Potential was used to guide the coding of visual and inferential meaning of the activities of MET nurses. CCNs coded over 6 h of videoed MET calls, sampled across three hospitals, Sydney, Australia. Results The first layer of coding contained 1042 discreet tasks. They were sorted into 15 Areas of Practice (AOPs) and then allocated to aspects of performance (psychomotor and cognitive). The AOPs ‘Assisting with Procedure’ through to ‘Monitoring Vital Signs’ reflect psychomotor skills which account for almost half (48%) of the AOPs at site 1 and three-quarters at sites 2 (70%) and 3 (78%). Eight generic responsibilities/roles were identified. ‘Ongoing Assessment,’ ‘Re-evaluating Risk’ and ‘Prioritising Interventions’ were the most prominent. The patterns differed by hospital: ‘Re-evaluating Risk’ was prominent for sites 1 and 2 but less so for site 3. Conclusion ‘Ongoing Assessment’ and ‘Re-evaluating Risk’ occupied almost half of the MET nurses time, whereas ‘Establishing Patient Acuity, the key activity in CA teams, occupied only 4%. These findings provide evidence of the roles of CCNs in the MET and suggest that education and training of MET nurses should support these roles.

Modelling Behaviour Semantically

Context is only one of several strata of meaning and we can not predict realisation at the lexical or grammatical level from context alone. Yet, there is a tendency to confuse contextual patterning with semantic patterning and allocate patterning to the contextual level that might better be dealt with on other levels. While much work has been done on theorising lexis and grammar and, more recently, on seeing these in context, much remains to be done on theorising semantics as a separate level mediating between context and lexis and grammar. This paper examines the problem of modelling behaviour and the challenge of understanding behaviour in context as well as on a semantical level. By understanding the descriptive responsibilities allocated to each level of language, we are better able to see what remains to be covered by context within a model.

Start Making Sense: Systemic-Functional Linguistics and Ambient Intelligence

An operational model of context is particularly important for the successful integration of new technical artefacts into complex processes. One of the challenges for ambient intelligence is to embed technical artefacts into human work processes in such a way that they support the sense making processes of human actors instead of placing new burdens upon them. This paper examines some of the strengths and current limitations of a systemic functional model of context. We propose that the dimensions that are relevant to modeling are those that have the most consequences for meaning. This is explored in a hypothetical hospital scenario.

'Construe My Meaning': Performance, Poetry and Semiotic Distance

These words, quoted from the Elizabethan madrigal by Giles Farnaby (1560–1640), evoke for me many of the dimensions of the thought and linguistic technique of Ruqaiya Hasan (e.g. Hasan, 2007). The primary point of Hasan’s emphasis is that a linguist should work so that all that is performed in linguistic analysis demonstrates its relevance to meaning. Second, in evaluating linguistic proposals, one needs to be assiduous in thinking through the implications of the theory — what the theory carries by way of its own meanings. Throughout Hasan’s semantic odyssey, there are then at least two levels of meaning for construe: it applies to the cultural and linguistic meaning under investigation through wording; and to the theoretical meanings that we bring with our modes of enquiry, and which are inherent in the terms of representation that we employ. With respect to the latter, ‘wrest not my method’ is also relevant: namely, do not take my method from me, or turn it to different purposes (more archaic).