Exploring shared decision making in breast cancer care: A case-based conversation analytic approach
Issue: Vol 16 No. 1 (2019)
Journal: Communication & Medicine
Subject Areas: Healthcare Communication Linguistics
DOI: 10.1558/cam.36775
Abstract:
Shared decision making (SDM) is acknowledged as the gold standard of healthcare communication, particularly relevant to preference-sensitive care such as breast cancer treatment. However, research on patients’ experiences shows a misalignment between clinicians’ goals and the rhetoric regarding patients’ empowerment during SDM for this treatment. This warrants detailed examination on the conversational dynamics of SDM, and this study aims to identify interactional features and social practices through which SDM is achieved. Fifteen audio recordings from adjuvant treatment breast cancer consultations were examined using the methodology of conversation analysis (CA), and recurrent patterns relevant for understanding SDM were identified. Boundary markers, rhetorical questioning and epistemic markers discouraged a shared orientation to patient participation, reinforcing perceived imbalanced doctor–patient power relations. Cues for SDM such as multi-turn utterances and spaces for transition were presented but not recognised by patients, resulting in sub-optimal two-way discussions about decision making. The findings also reveal that interactional practices were deployed that theoretically should have enabled patients to contribute to SDM. However, in reality these did not result in extended sequences of reciprocated contributions from practitioner and service user. SDM did not happen with the ease implied by current models, and the resultant interactions bore more similarity to expert-led, rather than collaborative, decision making
Author: Neda Mahmoodi, Georgina L. Jones, Tom Muskett, Sally Sargeant
References :
Alegría, Margarita, Nicholas Carson, Michael Flores, Xinliang Li Ping Shi, Anna-Sophia Lessios, Michelle Allen, Mary Fierro et al. (2014) Activation, self-management, engagement, and retention in behavioural health care: A randomized clinical trial of the DECIDE intervention. American Medical Association Psychiatry 71 (5): 557–565. https://doi.org/10.1001/jamapsychiatry.2013.4519
Arminen, Illka (2005) Institutional Interaction: Studies of Talk at Work, Volume 2. Aldershot, UK: Ashgate.
Barry, Michael J. and Susan Edgman-Levitan (2012) Shared decision making – The pinnacle of patient-centered care. New England Journal of Medicine 366: 780–781. https://doi.org/10.1056/NEJMp1109283
Berger, Zachary (2015) Navigating the unknown: Shared decision-making in the face of uncertainty. Journal of General Internal Medicine 30 (5): 675–678. https://doi.org/10.1007/s11606-014-3074-8
Charles, Cathy, Amiram Gafni and Tim Whelan (2004) Self-reported use of shared decision-making among breast cancer specialists and perceived barriers and facilitators to implementing this approach. Health Expectations 7 (4): 338–348. https://doi.org/10.1111/j.1369-7625.2004.00299.x
Chatwin, John (2014) Conversation analysis as a method for investigating interaction in care home environments. Dementia 13 (6): 737–746. https://doi.org/10.1177/1471301213485231
Chatwin, John, Penny Bee, Gary J. Macfarlane and Karina Lovell (2014) Observations on silence in telephone delivered cognitive behavioural therapy (T-CBT). Journal of Applied Linguistics and Professional Practice 11 (1): 1–22. https://doi.org/10.1558/japl.27652
Chewning, Betty, Carma L. Bylund, Bupendra Shah, Neeja K. Arora, Jennifer A. Gueguen and Gregory Makoul (2012) Patient preferences for shared decisions: A systematic review. Patient Education and Counselling 86 (1): 9–18. https://doi.org/10.1016/j.pec.2011.02.004
Collins, Sarah, Paul Drew, Ian Watt and Vikki Entwistle (2005) ‘Unilateral’ and ‘bilateral’ practitioner approaches in decision-making about treatment. Social Science & Medicine 61 (12): 2611–2627. https://doi.org/10.1016/j.socscimed.2005.04.047
De Haes, Hanneke (2006) Dilemmas in patient centeredness and shared decision-making: A case for vulnerability. Patient Education and Counselling 62 (3): 291–298. https://doi.org/10.1016/j.pec.2006.06.012
Department of Health (2010) Liberating the NHS: No Decision About Me Without Me. Government Response. London: Department of Health.
Drew, Paul, John Chatwin and Sarah Collins (2001) Conversation analysis: A method for research into interactions between patients and health-care professionals. Health Expectations 4 (1): 58–70. https://doi.org/10.1046/j.1369-6513.2001.00125.x
Duffin, Donna and Srikant Sarangi (2018) Shared decision or decision shared? Interactional trajectories in Huntington’s disease management clinics. Communication and Medicine 14 (3): 201–216. https://doi.org/10.1558/cam.36402
Elwyn, Glyn, Richard Gywn, Adrian Edwards and Richard Grol (1999) Is ‘shared decision-making’ feasible in consultations for upper respiratory tract infections? Assessing the influence of antibiotic expectations using discourse analysis. Health Expectations 2 (2): 105–117. https://doi.org/10.1046/j.1369-6513.1999.00045.x
Elwyn, Glyn, Amy Lloyd, Natalie Joseph-Williams, Emma Cording, Richard Thomson, Marie-Anne Durand and Adrian Edwards (2013) Option grids: Shared decision making made easier. Patient Education and Counselling 90 (2): 207–212. https://doi.org/10.1016/j.pec.2012.06.036
Elwyn, Glyn, Dominick Frosch, Richard Thomson, Natalie Joseph-Williams, Amy Lloyd, Paul Kinnersley, Emma Cording et al. (2012) Shared decision-making: A model for clinical practice. Journal of General International Medicine 27 (10): 1361–1367. https://doi.org/10.1007/s11606-012-2077-6
Fentiman, Ian. S. (2007). Communication with older breast cancer patients. Breast Journal 13 (4): 406–409. https://doi.org/10.1111/j.1524-4741.2007.00449.x
Fraser, Bruce. (1999) What are discourse markers? Journal of Pragmatics 31 (7): 931–952. https://doi.org/10.1016/S0378-2166(98)00101-5
Frosch, Dominck L., Kirsty J. Singer and Stefan Timmermans (2011) Conducting implementation research in community-based primary care: A qualitative study on integrating patient decision support interventions for cancer screening into routine practice. Health Expectations 14 (Suppl. 1): 73–84. https://doi.org/10.1111/j.1369-7625.2009.00579.x
Frosch, Dominck L., Suepattra G. May, Katherine A. Rendle, Caroline Tietbohl and Glyn Elwyn (2012) Authoritarian physicians and patients’ fear of being labelled ‘difficult’ among key obstacles to shared decision-making. Health Affairs 31 (5): 1030–1038. https://doi.org/10.1377/hlthaff.2011.0576
Grimen, Harald (2009) Power, trust, and risk. Medical Anthropology Quarterly 23 (1): 16–33. https://doi.org/10.1111/j.1548-1387.2009.01035.x
Hargraves, Ian and Victor M. Montori (2014) Decision aids, empowerment, and shared decision making. British Medical Journal 349: g5811. https://doi.org/10.1136/bmj.g5811
Ha, Jennifer F. and Nancy Longnecker (2010) Doctor-patient communication: A review. The Ochsner Journal 10 (1): 38–43.
Health Foundation (2013) Implementing Shared Decision Making: Clinical Teams’ Experiences of Implementing Shared Decision Making as Part of The MAGIC Programme. London: Health Foundation.
Heritage, John and Douglas W. Maynard (2005) Communication in Medical Care: Interactions between Primary Care Physicians and Patients. Cambridge: Cambridge University Press.
Heritage, John and Tanya Stivers (1999) Online commentary in acute medical visits: A method of shaping patient expectations. Social Science and Medicine 49 (11): 1501–1517. https://doi.org/10.1016/S0277-9536(99)00219-1
Jefferson, Gail (2004) Glossary of transcript symbols with an introduction. In Gene H. Lerner (eds) Conversation Analysis: Studies from The First Generation, 13–31. Philadelphia: John Benjamins. https://doi.org/10.1075/pbns.125.02jef
Joseph-Williams, Natalie, Glyn Elwyn and Adrian Edwards (2014) Knowledge is not power for patients: A systematic review and thematic synthesis of patient-reported barriers and facilitators to shared decision-making. Patient Education and Counselling 94 (3): 291–309. https://doi.org/10.1016/j.pec.2013.10.031
Joseph-Williams, Natalie, Amy Lloyd, Adrian Edwards, Lynne Stobbart, David Tomson, Sheila Macphail, Carole Dodd et al. (2017) Implementing shared decision making in the NHS: Lessons from the MAGIC programme. British Medical Journal 357: j1744. https://doi.org/10.1136/bmj.j1744
Keating, Nancy L., Edward Guadagnoli, Mary Beth Landrum, Catherine Borbas and Jane C. Weeks (2002) Treatment decision-making in early-stage breast cancer: Should surgeons match patients’ desired level of involvement? Journal of Clinical Oncology 20 (6): 1473–1479. https://doi.org/10.1200/JCO.2002.20.6.1473
Landmark, Anne-Marie D., Pal Gulbrandsena and Jan Svennevig (2015) Whose decision? Negotiating epistemic and deontic rights in medical treatment decisions. Journal of Pragmatics 78: 54–69. https://doi.org/10.1016/j.pragma.2014.11.007
Lee, Joy, Wynne Callon, Carlton Haywood Jr., Sophie M. Lanzkron, Pal Gulbrandsen and Mary Catherine Beach (2018) What does shared decision making look like in natural settings? A mixed methods study of patient–provider conversations. Communication and Medicine 14 (3): 217–228. https://doi.org/10.1558/cam.32815
Légaré, France, Stephane Ratté, Karine Gravel and Ian D. Graham (2008) Barriers and facilitators to implementing shared decision-making in clinical practice: Update of a systematic review of health professionals’ perceptions. Patient Education and Counselling 73: 526–535. https://doi.org/10.1016/j.pec.2008.07.018
Légaré, France, Stephane Ratté, Dawn Stacey, Jennifer Kryworuchko, Karine Gravel, Ian D. Graham and Stephane Turcotte (2010) Interventions for improving the adoption of shared decision-making by healthcare professionals. Cochrane Database Systematic Reviews 5: Art. CD006732. https://doi.org/10.1002/14651858.CD006732.pub2
Linell, Per and Thomas Luckmann (1991) Asymmetries in dialogue: Some conceptual preliminaries. In Ivana Marková and Klaus Foppa (eds) Asymmetries in Dialogue, 1–20. Hemel Hempstead, UK: Harvester Wheatsheaf.
Mahmoodi, Neda and Sally Sargeant (2017) Shared decision-making – Rhetoric and reality: Women’s experiences and perceptions of adjuvant treatment decision-making for breast cancer. Journal of Health Psychology 24 (8): 1082–1092. https://doi.org/10.1177/1359105316689141
Meyer, Christine B. (2001) A case study in case study methodology. Field Methods 13 (4): 329–352. https://doi.org/10.1177/1525822X0101300402
Moumjid, Nora, Amiram Gafni, Alain Brémond and Marie-Odile Carrère (2007) Shared decision-making in the medical encounter: Are we all talking about the same thing? Medical Decision Making 27 (5): 539–546. https://doi.org/10.1177/0272989X07306779
National Institute for Health and Care Excellence (2016) Shared Decision-Making Collaborative: A Consensus Statement. London: National Institute for Clinical Excellence (NICE).
O’Flynn, Norma and Nicky Britten (2006) Does the achievement of medical identity limit the ability of primary care practitioners to be patient-centred? A qualitative study. Patient Education and Counselling 60 (1): 49–56. https://doi.org/10.1016/j.pec.2004.12.002
Peräkylä, Anssi (1999) Conversation analysis: A new model of research in doctor-patient communication. Journal of the Royal Society of Medicine 90 (4): 205–208. https://doi.org/10.1177/014107689709000406
Peräkylä, Anssi (2002) Agency and authority: Extended responses to diagnostic statements in primary care encounters. Research on Language and Social Interaction 35 (2): 219–247. https://doi.org/10.1207/S15327973RLSI3502_5
Pilnick, Alison and Robert Dingwall (2011) On the remarkable persistence of asymmetry in doctor/patient interaction: A critical review. Social Science and Medicine 72 (8): 1374–1382. https://doi.org/10.1016/j.socscimed.2011.02.033
Pomerantz, Anita (1984) Agreeing and disagreeing with assessments: Some features of preferred/dispreferred turn shapes. In Maxwell J. Atkinson and John Heritage (eds) Structures of Social Action, 57–101. Cambridge: Cambridge University Press. https://doi.org/10.1017/CBO9780511665868.008
Robinson, Jeffery D. (2001) Asymmetry in action: Sequential resources in the negotiation of a prescription request. Text & Talk 21 (1–2): 19–54. https://doi.org/10.1515/text.1.21.1-2.19
Shepherd, Heather L., Alexandra Barratt, Lyndal J. Trevena, Kevin McGeechan, Karen Carey, Ronald M. Epstein, Phyllis N. Butow et al. (2011) Three questions that patients can ask to improve the quality of information physicians give about treatment options: A cross-over trial. Patient Education and Counselling 84 (3): 379–385. https://doi.org/10.1016/j.pec.2011.07.022
Skelton, John R., Andy M. Wearn and Richard F. Hobbs (2002) ‘I’ and ‘we’: A concordancing analysis of how doctors and patients use first person pronouns in primary care consultations. Family Practice 19 (5): 484–488. https://doi.org/10.1093/fampra/19.5.484
Street, Richard L. and Becky Voigt (1997) Patient participation in deciding breast cancer treatment and subsequent quality of life. Medical Decision Making 17 (3): 298–306. https://doi.org/10.1177/0272989X9701700306
Stevanovic, Melisa (2012) Establishing joint decisions in a dyad. Discourse Studies 14 (6): 779–803. https://doi.org/10.1177/1461445612456654
Stivers, Tanya and John Heritage (2001) Breaking the sequential mold: Answering ‘more than the question’ during comprehensive history taking. Text & Talk 21 (1–2): 151–185. https://doi.org/10.1515/text.1.21.1-2.151
Willig, Carla (2008) Introducing Qualitative Research in Psychology: Adventures in Theory and Method (2nd edition). Buckingham, UK: Open University Press.