Patient participation in decision making process in primary care: a conversation analytic study

Abstract

Tutkimus kuvaa, miten potilaat osallistuvat diagnoosia ja hoitoa koskevaan päätöksentekoon terveyskeskuslääkärin vastaanotolla. Tutkimuksen aineistona ovat 98 videoitua lääkärin vastaanottoa, joilla kaikilla potilas kärsii ylähengitystieinfektio-oireista. Aineiston analyysimenetelmä on keskustelunanalyysi.

Tutkimuksessa tarkastellaan kolmea vastaanoton vaihetta: potilaan vaivan kuvausta ja vastaanottamista, diagnoosin kertomista ja vastaanottamista sekä hoitopäätöksen antamista ja siihen vastaamista.

Tutkimuksen keskeinen tulos on, että tapa jolla potilas kuvaa vaivaansa, on merkityksellinen sen suhteen miten lääkäri suhtautuu potilaaseen vaivaansa koskevan tiedon tuottajana paitsi vastaanoton alussa, myös kertoessaan diagnoosin vastaanoton myöhemmässä vaiheessa; diagnoosin kerronnassa lääkärit huomioivat tavan miten potilas vaivaansa kuvasi. Tämä osoittaa, että potilaan osallistumisen tapa vastaanoton alussa muokkaa vastaanottovuorovaikutuksen kulkua läpi vastaanoton.

Tutkimuksessa tarkastellaan myös, miten potilaat osallistuvat hoitopäätöksentekoon vastaanotolla. Analyysin kohteena ovat lääkäreiden tavat antaa hoitopäätös yksipuolisesti , ts. lääkärin jo tekemänä päätöksenä jonka sisältöön ei sinällään odoteta potilaan näkökulmaa. Vaikka lääkäri ei näin ollen rohkaisekaan potilaan osallistumista millään erityisellä tavalla, on potilaalla silti mahdollisus osallistua hoitopäätöksen tekoon ja jopa vaikuttaa lopulliseen päätökseen aloittamalla neuvottelu lääkärin esittämän päätöksen hyväksyttävyydestä.

Tutkimus osoittaa, että potilaan osallistumisen tavat lääkärin vastaanotolla ovat moninaisemmat ja usein epäsuoremmat kuin esimerkiksi kysymysten esittäminen lääkärille. Vastaanottovuorovaikutuksen laatua tarkastellessa tulisikin kiinnittää huomiota koko vastaanoton kulkuun yksittäisten tapahtumien lisäksi.

This study examines how patients participate in the diagnostic and treatment decision making in Finnish primary care consultations for upper respiratory tract infection. The study focuses on doctor-patient interaction in three phases of a consultation: problem presentation, diagnosis delivery and treatment decision making and examines how these phases are linked to each other, forming a process of diagnostic and treatment decision making within the consultation. The data of this study consist of ninety-eight video- and audio-recorded doctorpatient encounters that were collected in nine municipal health centres in different parts of Finland in 2005-2006. Eighty-six encounters were selected into the detailed analysis: forty-six child patient encounters and forty adult patient encounters. The method of the study is ethnomethodological conversation analysis. The results are presented in four empirical articles that are published/accepted to be published in peer-reviewed scientific journals.

The study examines how doctors and patients epistemic positions are interactionally constructed and oriented to in presenting and receiving a reason for the visit. Firstly, front-grounded and back-grounded candidate diagnoses were discerned from the symptoms only type of problem presentations. When a patient presents symptoms only , the doctors receive this type of symptom descriptions minimally, without contemplating the patient s experience as such and the patient s and the doctor s epistemic positions are oriented to as conventional doctor-patient roles. When the patient presents a candidate diagnosis in her or his problem presentation, the doctors typically address it right then and there: the patient s problem presentation guides the doctor s responsive actions in terms of when and how the doctors take the patient s epistemic position into account, and how the doctors orient to the patients rights to possess medical knowledge. Further, the doctor s diagnosis delivery serves as an interactionally responsive and thus relevant action with regard to the way in which the patient presented the problem earlier in the visit. Therefore, the patient s problem presentation and the doctor s diagnosis delivery constitutes a request-grant type of activity in the consultation. As doctors design their diagnosis deliveries to be responsive to the patient s problem presentation, they treat themselves accountable for meeting the patient s particular agenda in the consultation. Moreover, the study shows how patients resist a diagnosis given by a doctor and how they re-invoke the reference between the problem presentation and diagnosis delivery in cases in which the doctor s diagnosis does not fit the initial complaint. In resisting, patients resort not only to their experience-based views on their illness to which they are entitled to, but also on medically informed knowledge on their previous diagnoses. This is evident when the patients reinvoke their own initial diagnostic expectations: the diagnosis is something on which the patient has a say not only in presenting the problem at the beginning of the encounter but also later on, upon hearing the doctor s diagnosis.

The study also examines the ways in which the doctors and patients arrive at treatment decisions following a doctor s unilateral decision delivery. The term unilateral refers to decision delivery formats within which the doctors suggest, recommend or conclude a treatment or some other further plan of action to the patient and which are given as initiative actions in the decision making phase, thus offering the decision as already-made. However, even in unilateral decision deliveries doctors typically accommodate the patient s perspective to it: they make the medical rationale of the decision making available to the patient and/or refer to the patient s possible diagnostic or treatment expectations in delivering the decision. This way, the doctor s decision is not presented as the conclusion of his/her medical opinion only but also as a response to the patient s expectation. The ways in which the patients receive these decision deliveries either maintain the orientation in the decision making in doctor-controlled agency, or shape the orientation toward a more shared practice. Firstly, by absent or minimal response to the decision delivery and aligning with the initiation of the next activity after the decision delivery, patients may orient to the conduct in unilateral decision making as adequate. In turn, in their extended responses the patients further their own perspectives in decision making by assessing the decision positively, by evaluating the grounds on which the doctor s decision is acceptable, or by resisting the decision. Again, in extending the sequence of decision delivery and reception, the patients orient to the decision as negotiable and shape the unilateral process of decision making into a shared one.

The results of the study are discussed in relation to concepts such as patient participation, concordance and shared decision making that are used in current health policy and research. The study also considers the viewpoints which empiric, conversation analytic research can bring to the theoretical discussion.