Jeffrey D. Robinson

Reducing Patients’ Unmet Concerns in Primary Care: the Difference One Word Can Make

ContextIn primary, acute-care visits, patients frequently present with more than 1 concern. Various visit factors prevent additional concerns from being articulated and addressed.ObjectiveTo test an intervention to reduce patients’ unmet concerns.DesignCross-sectional comparison of 2 experimental questions, with videotaping of office visits and pre and postvisit surveys.SettingTwenty outpatient offices of community-based physicians equally divided between Los Angeles County and a midsized town in Pennsylvania.ParticipantsA volunteer sample of 20 family physicians (participation rate = 80%) and 224 patients approached consecutively within physicians (participation rate = 73%; approximately 11 participating for each enrolled physician) seeking care for an acute condition.InterventionAfter seeing 4 nonintervention patients, physicians were randomly assigned to solicit additional concerns by asking 1 of the following 2 questions after patients presented their chief concern: “Is there anything else you want to address in the visit today?” (ANY condition) and “Is there something else you want to address in the visit today?” (SOME condition).Main Outcome MeasuresPatients’ unmet concerns: concerns listed on previsit surveys but not addressed during visits, visit time, unanticipated concerns: concerns that were addressed during the visit but not listed on previsit surveys.ResultsRelative to nonintervention cases, the implemented SOME intervention eliminated 78% of unmet concerns (odds ratio (OR) = .154, p = .001). The ANY intervention could not be significantly distinguished from the control condition (p = .122). Neither intervention affected visit length, or patients’; expression of unanticipated concerns not listed in previsit surveys.ConclusionsPatients’ unmet concerns can be dramatically reduced by a simple inquiry framed in the SOME form. Both the learning and implementation of the intervention require very little time.

A preference for progressivity in interaction

This article investigates two types of preference organization in interaction: in response to a question that selects a next speaker in multi-party interaction, the preference for answers over non-answer responses as a category of a response; and the preference for selected next speakers to respond. It is asserted that the turn allocation rule specified by Sacks, Schegloff & Jefferson(1974)whichstatesthataresponseisrelevantbytheselectednextspeaker at the transition relevance place is affected by these two preferences once beyond a normal transition space. It is argued that a “second-order” organizationispresentsuchthatinteractantsprioritizeapreferenceforanswersover apreferenceforaresponsebytheselectednextspeaker.Thisanalysisreveals an observable preference for progressivity in interaction. (Interaction, conversation analysis, preference, sequence organization.)*

The Architecture of Provider-Parent Vaccine Discussions at Health Supervision Visits

OBJECTIVE: To characterize provider-parent vaccine communication and determine the influence of specific provider communication practices on parent resistance to vaccine recommendations. METHODS: We conducted a cross-sectional observational study in which we videotaped provider-parent vaccine discussions during health supervision visits. Parents of children aged 1 to 19 months old were screened by using the Parent Attitudes about Childhood Vaccines survey. We oversampled vaccine-hesitant parents (VHPs), defined as a score ≥50. We developed a coding scheme of 15 communication practices and applied it to all visits. We used multivariate logistic regression to explore the association between provider communication practices and parent resistance to vaccines, controlling for parental hesitancy status and demographic and visit characteristics. RESULTS: We analyzed 111 vaccine discussions involving 16 providers from 9 practices; 50% included VHPs. Most providers (74%) initiated vaccine recommendations with presumptive (eg, “Well, we have to do some shots”) rather than participatory (eg, “What do you want to do about shots?”) formats. Among parents who voiced resistance to provider initiation (41%), significantly more were VHPs than non-VHPs. Parents had significantly higher odds of resisting vaccine recommendations if the provider used a participatory rather than a presumptive initiation format (adjusted odds ratio: 17.5; 95% confidence interval: 1.2–253.5). When parents resisted, 50% of providers pursued their original recommendations (eg, “He really needs these shots”), and 47% of initially resistant parents subsequently accepted recommendations when they did. CONCLUSIONS: How providers initiate and pursue vaccine recommendations is associated with parental vaccine acceptance.

Frame Negotiation in Doctor-Elderly Patient Consultations

Institutional discourse typically involves a dialectic between institutional (e.g. medical) frames and socio-relational frames for talk. The paper draws on audio-recorded data from a geriatric outpatients clinic in the UK to show how doctors and elderly patients collaborate in and negotiate the work of entering an apparently medical frame of talk. Particular attention is paid to sequences involving how are you?-type elicitations. Social and medical framings of talk are established and blended in complex discourse patterns. This blending may have a special salience in contexts, such as geriatrics, where holistic care has an explicit priority.

Intervening With Conversation Analysis: The Case of Medicine

In this article, we discuss the notion of a ‘conversation analytic intervention,’ focusing on the role of conversation analysis in the major stages of intervention research, epitomized by the randomized controlled trial, the gold standard for intervention in the medical sciences. These stages embrace development, feasibility and piloting, evaluation, and implementation. We describe how conversation analytic methods are used as part of the first two stages and how a conversation analytic skill base and sensibility must be deployed in managing the last two stages. Through a review of practical requirements for successful, externally-funded intervention research, we provide suggestions for how to maximize the potential for basic, conversation analytic research to eventuate in intervention. Data are in American English.

The Influence of Provider Communication Behaviors on Parental Vaccine Acceptance and Visit Experience.

OBJECTIVES We investigated how provider vaccine communication behaviors influence parental vaccination acceptance and visit experience. METHODS In a cross-sectional observational study, we videotaped provider-parent vaccine discussions (n = 111). We coded visits for the format providers used for initiating the vaccine discussion (participatory vs presumptive), parental verbal resistance to vaccines after provider initiation (yes vs no), and provider pursuit of recommendations in the face of parental resistance (pursuit vs mitigated or no pursuit). Main outcomes were parental verbal acceptance of recommended vaccines at visits end (all vs ≥ 1 refusal) and parental visit experience (highly vs lower rated). RESULTS In multivariable models, participatory (vs presumptive) initiation formats were associated with decreased odds of accepting all vaccines at visits end (adjusted odds ratio [AOR] = 0.04; 95% confidence interval [CI] = 0.01, 0.15) and increased odds of a highly rated visit experience (AOR = 17.3; 95% CI = 1.5, 200.3). CONCLUSIONS In the context of 2 general communication formats used by providers to initiate vaccine discussions, there appears to be an inverse relationship between parental acceptance of vaccines and visit experience. Further exploration of this inverse relationship in longitudinal studies is needed.

Using Full Repeats to Initiate Repair on Others’ Questions

This article is a conversation-analytic investigation of a previously undescribed practice of other-initiation of repair designed to locate an entire action as the repairable. This practice is implemented by a full, virtually identical, final-rising-intoned repeat of a sentential turn-constructional unit (a full repeat). This article focuses on how the full repeat is deployed to deal with one type of action, the question (i.e., a first-pair part whose primary action is one of requesting information in the vernacular sense). The full repeat delimits the nature of the trouble by working to rule out that of hearing-what-was-said and understanding-that-a-question-was-asked. The full repeat tacitly claims that a questioning action is somehow problematic. The nature of this problem can be one of either understanding the questioning action (i.e., trouble understanding the thrust of the question-as-a-whole, or what it is getting at, or what is meant by its asking), or accepting the questioning action (e.g., characterizing it as being ridiculous). Data are approximately 80 hours of audio- and videotaped mundane conversation between adult friends and family members.

Preference organization of sequence-initiating actions: The case of explicit account solicitations

This article extends prior conversation analytic research on the preference organization of sequence-initiating actions. Across two languages (English and Russian), this article examines one such action: explicitly soliciting an account for human conduct (predominantly with why-type interrogatives). Prior work demonstrates that this action conveys a challenging stance towards the warrantability of the accountable event/conduct (Bolden and Robinson, forthcoming). When addressees are somehow responsible for the accountable event/conduct, explicit solicitations of accounts are frequently critical of, and thus embody disaffiliation with, addressees. This article demonstrates that, when explicit solicitations of accounts embody disaffiliation, they are systematically ‘withheld’ and, thus, can be characterized as ‘dispreferred’ actions. This article also examines: a) deviant cases, where account solicitations are not withheld, which is a practice for embodying aggravated disaffiliation; and b) negative cases, where account solicitations actually embody affiliation , and as such are typically treated as preferred actions and not withheld.

Communication Practices and Antibiotic Use for Acute Respiratory Tract Infections in Children

PURPOSE This study examined relationships between provider communication practices, antibiotic prescribing, and parent care ratings during pediatric visits for acute respiratory tract infection (ARTI). METHODS A cross-sectional study was conducted of 1,285 pediatric visits motivated by ARTI symptoms. Children were seen by 1 of 28 pediatric providers representing 10 practices in Seattle, Washington, between December 2007 and April 2009. Providers completed post-visit surveys reporting on children’s presenting symptoms, physical examination findings, assigned diagnoses, and treatments prescribed. Parents completed post-visit surveys reporting on provider communication practices and care ratings for the visit. Multivariate analyses identified key predictors of prescribing antibiotics for ARTI and of parent visit ratings. RESULTS Suggesting actions parents could take to reduce their child’s symptoms (providing positive treatment recommendations) was associated with decreased risk of antibiotic prescribing whether done alone or in combination with negative treatment recommendations (ruling out the need for antibiotics) [adjusted risk ratio (aRR) 0.48; 95% CI, 0.24–0.95; and aRR 0.15; 95% CI, 0.06–0.40, respectively]. Parents receiving combined positive and negative treatment recommendations were more likely to give the highest possible visit rating (aRR 1.16; 95% CI, 1.01–1.34). CONCLUSION Combined use of positive and negative treatment recommendations may reduce the risk of antibiotic prescribing for children with viral ARTIs and at the same time improve visit ratings. With the growing threat of antibiotic resistance at the community and individual level, these communication techniques may assist frontline providers in helping to address this pervasive public health problem.

Interventional Magnetic Resonance Imaging in the Head and Neck

Interventional MRI is clearly in its early stages of development. While the value of MR-guided aspiration cytology and MR evaluation of deep electrode implantation in the brain has already been confirmed with human clinical studies, the future of MR-guided interstitial laser therapy remains to be proven. Despite this, as we look ahead into the 1990s and the millennium, it is possible to imagine dedicated MR laser therapy units for combined radiological and surgical outpatient approaches in what may become the operating rooms of the 21st century.