Rebecca Barnes

Diagnostic formulations in psychotherapy

Conversation analysts have noted that, in psychotherapy, formulations of the clients talk can be a vehicle for offering a psychological interpretation of the clients circumstances. But we notice that not all formulations in psychotherapy offer interpretations. We offer an analysis of formulations (both of the gist of the clients words and of their implications) that are diagnostic: that is, used by the professional to sharpen, clarify or refine the clients account and make it better able to provide what the professional needs to know about the clients history and symptoms. In doing so, these formulations also have the effect of shepherding the clients account towards subsequent therapeutic interpretation. In a coda, we notice that sometimes the formulations are designed discreetly. We examine one such discreet formulation in detail, and show how its very ambiguity can lead to its failure as a diagnostic probe.

Formulations and the facilitation of common agreement in meetings talk

Abstract Meetings are a place where shared understanding is paramount and must be done in an economical manner in line with the goals of most institutional interactions. Drawing from classic work in conversation analysis, this paper reports on an examination of a corpus of eight hours of video-recorded meeting interactions from a medical school. Mostly, meetings involve knowledge sharing and an orientation to decision making. Common agreement is highly important where elaborate effort may be invested by the chair to get agreement to what the outcomes were. In the data studied there are marked orientations toward common agreement. A particular subclass of formulations is one device employed to these ends by the chair—candidate preclosings (Garfinkel and Sacks 1970). This paper focuses on these particular formulations—types of repeat utterances that are designed to be recognized as linked to previous discussions but completely gloss the preceding talk. The analysis focuses on the sequential environment embodied by this glossing practice, demonstrating the basic format of production and its interactional consequences. In conclusion it is argued that these formulations are used by chairpersons to close the business-at-hand and facilitate the move on to the next topic. They also help to establish, record, and preserve shared understanding incrementally in a time-limited task-focused environment.

Conversation analysis: a practical resource in the health care setting.

In this commentary I shall reflect on the critical mass of conversation analytic and ethnomethodological studies of health care work practices. I describe the breadth of coverage of these studies by both first and second generation conversation analysts, from the UK to the Netherlands and Scandinavia, across to America and Canada. I argue that these studies represent some of the best examples of applied conversation analytic research to date and are an underused resource for both health care educators and practitioners. To conclude I signpost the future and how the practical applications of such work, if clearly articulated and publicised, could play a significant part in improving patient care.

Treatment Recommendations as Actions

ABSTRACT From the earliest studies of doctor-patient interaction (Byrne & Long, 1976), it has been recognized that treatment recommendations may be expressed in more or less authoritative ways, based on their design and delivery. There are clear differences between I’m going to start you on X and We can give you X to try and Would you like me to give you X? Yet little is known about this variation, its contexts, or its consequences. In this paper, we develop a basic taxonomy of treatment recommendations in primary care as a first step toward a more comprehensive investigation. We take as our point of departure the observation that treatment recommendations such as those above represent not only different formulations but also different social actions. We distinguish five main treatment recommendation actions: pronouncements, suggestions, proposals, offers, and assertions. We ask: what are the main dimensions on which these recommendations vary and to what end? And what sorts of factors shape a clinician’s use of one action type over another with respect to recommending a medication in the primary care context?

The 'One in a Million' study: creating a database of UK primary care consultations

Background Around 1 million primary care consultations happen in England every day. Despite this, much of what happens in these visits remains a ‘black box’. Aim To create an archive of videotaped consultations and linked data based on a large sample of routine face-to-face doctor–patient consultations with consent for use in future research and training. Design and setting Cross-sectional study in 12 general practices in the west of England, UK. Method Up to two GPs from each practice took part in the study. Over 1 to 2 days, consecutive patients were approached until up to 20 eligible patients for each GP consented to be videotaped. Eligible patients were aged ≥18 years, consulting on their own behalf, fluent in English, and with capacity to consent. GP questionnaires were self-administered. Patient questionnaires were self-administered immediately pre-consultation and post-consultation, and GPs filled in a checklist after each recording. A follow-up questionnaire was sent to patients after 10 days, and data about subsequent related consultations were collected from medical records 3 months later. Results Of the 485 patients approached, 421 (86.8%) were eligible. Of the eligible patients, 334 (79.3%) consented to participate and 327 consultations with 23 GPs were successfully taped (307 video, 20 audio-only). Most patients (n = 300, 89.8%) consented to use by other researchers, subject to specific ethical approval. Conclusion Most patients were willing to allow their consultations to be videotaped, and, with very few exceptions, to allow recordings and linked data to be stored in a data repository for future use for research and training.

Birdsong and footprints: tangibility and intangibility in a mindfulness research project

In this paper we attempt to describe and reflexively consider our journey through a particular qualitative health research project as experienced within a practitioner–researcher partnership. Our particular partnership was between a clinical psychologist and a conversation analyst who came together to explore participants’ experiences of a mindfulness‐based self‐help group. Using extracts from participant interviews and actual self‐help group discussion we tell our story, in order to practically demonstrate the challenges that arose. We consider the impact of mindfulness on the research process itself, in particular notions of tangibility and intangibility that were made increasingly relevant within our partnership.

Treatment Recommendation Actions, Contingencies, and Responses: An Introduction

ABSTRACT In the era of patient participation in health care decision making, we know surprisingly little about the ways in which treatment recommendations are made, the contexts that shape their formulation, and the consequences of these formulations. In this article, we introduce a systematic collective investigation of how recommendations for medications are responded to and made in primary versus secondary care, in the US versus the UK, and in contexts where the medication was over the counter versus by prescription. This article provides an overview of the coding system that was used in this project including describing what constitutes a recommendation, the primary action types clinicians use for recommendations, and the types of responses provided by patients to recommendations.

How do healthcare professionals interview patients to assess suicide risk

BackgroundThere is little evidence on how professionals communicate to assess suicide risk. This study analysed how professionals interview patients about suicidal ideation in clinical practice.MethodsThree hundred nineteen video-recorded outpatient visits in U.K. secondary mental health care were screened. 83 exchanges about suicidal ideation were identified in 77 visits. A convenience sample of 6 cases in 46 primary care visits was also analysed. Depressive symptoms were assessed. Questions and responses were qualitatively analysed using conversation analysis. χ2 tested whether questions were influenced by severity of depression or influenced patients’ responses.ResultsA gateway closed question was always asked inviting a yes/no response. 75% of questions were negatively phrased, communicating an expectation of no suicidal ideation, e.g., “No thoughts of harming yourself?”. 25% were positively phrased, communicating an expectation of suicidal ideation, e.g., “Do you feel life is not worth living?”. Comparing these two question types, patients were significantly more likely to say they were not suicidal when the question was negatively phrased but were not more likely to say they were suicidal when positively phrased (χ2 = 7.2, df = 1, p = 0.016). 25% patients responded with a narrative rather than a yes/no, conveying ambivalence. Here, psychiatrists tended to pursue a yes/no response. When the patient responded no to the gateway question, the psychiatrist moved on to the next topic. A similar pattern was identified in primary care.ConclusionsPsychiatrists tend to ask patients to confirm they are not suicidal using negative questions. Negatively phrased questions bias patients’ responses towards reporting no suicidal ideation.

Fit for work? How GPs' decisions about fitness to work can improve health.

GPs’ long-standing role in the sickness certification process in the UK has recently been under greater scrutiny due to policy focusing on the cost of sickness leave and the health benefits of keeping people in work. While the original certification policy was concerned primarily with incapacity and ensuring that claims for benefits were valid, recent policies place more emphasis on patients’ capacity to remain in work. Most GPs will recognise that taking a break from stressful or inappropriate employment may aid recovery for some but that staying in work may also be beneficial.1 This editorial, informed by recent guidance and evidence, will consider the key issues pertinent to sickness certification decision making and the new Fit for Work referral scheme;2 an optional resource for individuals who are employed, but are either currently unable to work or struggling. Fit notes replaced sick notes in April 2010 with much fanfare, but there is mixed evidence as to whether substantive changes have occurred. Qualitative research suggests that some doctors have used fit notes to stress the benefits of work and that patients have stated that they do not object to such conversations. Employers have also found the detailed comments by GPs within the fit notes useful, particularly when the ‘may be fit for work’ box is ticked.3 However, the box is only ticked on 6.4% of certificates (range by practice, 1–15%)4 and a recent report investigating the use of fit notes concluded that while they have not achieved all their objectives, progress is being made.5 The launch of the Fit for Work initiative coincides with the publication of the first two …

Question design in nurse-led and GP-led telephone triage for same-day appointment requests: a comparative investigation.

Objective To compare doctors’ and nurses’ communication with patients in primary care telephone triage consultations. Design Qualitative comparative study of content and form of questions in 51 telephone triage encounters between practitioners (general practitioners (GPs)=29; nurses=22) and patients requesting a same-day appointment in primary care. Audio-recordings of nurse-led calls were synchronised with video recordings of nurses use of computer decision support software (CDSS) during triage. Setting 2 GP practices in Devon and Warwickshire, UK. Participants 4 GPs and 29 patients; and 4 nurses and 22 patients requesting a same-day face-to-face appointment with a GP. Main outcome measure Form and content of practitioner-initiated questions and patient responses during clinical assessment. Results A total of 484 question–response sequences were coded (160 GP; 324 N). Despite average call lengths being similar (GP=4 min, 37 s, (SD=1 min, 26 s); N=4 min, 39 s, (SD=2 min, 22 s)), GPs and nurses differed in the average number (GP=5.51, (SD=4.66); N=14.72, (SD=6.42)), content and form of questions asked. A higher frequency of questioning in nurse-led triage was found to be due to nurses’ use of CDSS to guide telephone triage. 89% of nurse questions were oriented to asking patients about their reported symptoms or to wider-information gathering, compared to 54% of GP questions. 43% of GP questions involved eliciting patient concerns or expectations, and obtaining details of medical history, compared to 11% of nurse questions. Nurses using CDSS frequently delivered questions designed as declarative statements requesting confirmation and which typically preferred a ‘no problem’ response. In contrast, GPs asked a higher proportion of interrogative questions designed to request information. Conclusions Nurses and GPs emphasise different aspects of the clinical assessment process during telephone triage. These different styles of triage have implications for the type of information available following nurse-led or doctor-led triage, and for how patients experience triage.