A. Risk and uncertainty

(1) Lian OS, Nettleton S, Wifstad Å and Dowrick C (2021) Negotiating uncertainty in clinical encounters: A narrative exploration of naturally occurring primary care consultations. Social Science & Medicine 291 (114467). https://doi.org/10.1016/j.socscimed.2021.114467.

Study design: Based on a narrative analysis of 20 naturally occurring clinical consultations between general practitioners and patients in England, sourced from the One in a million data archive, we explore how they conceptualize and negotiate medical and existential uncertainty. To capture the interactional element, which is often overlooked, three consultations receive special attention. While exploring the ongoing dynamics of the moment-to-moment realization of negotiations, we relate their actions to the institutionalized positions of doctor and patient. Situating their negotiations in the sociocultural context in which their interaction is embedded reveals how consultations unfold as a result of communication between two different positions in a normatively structured system.

Main findings: When uncertainty prevails, both patients and GPs mainly conceptualize uncertainty indirectly. By conceptualizing uncertainty indirectly and in a depersonalized manner, GPs manage to safeguard against clinical errors without compromising their authority and credibility. Contrary to medical uncertainty, which is continuously discussed, existential uncertainty usually recedes in the background. However, as our consultations unfold it becomes evident that medical and existential dimensions of uncertainty are inextricably linked.

Practice implications: By acknowledging that clinical uncertainty is not only an epistemic concern but also an existential one, existential aspects may usefully rise to the surface.

(2) Lian OS, Nettleton S, Grange H and Dowrick C (2023) ‘I’d best take out life insurance, then.’ Conceptualisations of risk and uncertainty in primary care consultations, and implications for shared decision-making. Health, Risk & Society, vol. 25. https://doi.org/10.1080/13698575.2023.2197780.

Main objective: The main objective of this study is to gain knowledge about interactional factors that support and obstruct mutual risk-assessments and shared decision-making (SDM) in clinical consultations.

Methodology: Through a narrative analysis of verbatim transcripts of 28 naturally occurring consultations performed in English National Health Service practices, we explore the ways in which patients and general practitioners conceptualise, construct and negotiate risks related to diagnostic tests and medical treatments. Consultations were sampled from a corpus of 212 consultation transcripts from the One in a Million: Primary care consultations archive on the basis that they contained the word ‘risk(s)’. Most sampled cases relate to cardiovascular conditions and cancer.

Main findings: Drawing on a social constructionist perspective and the relational theory of risk, we found that while GPs talked about mathematical-probabilistic population risk, patients expressed their own experiences of possible future dangers, conceptualised through words like ‘worried’, ‘scared’ and ‘concerned’. Risk objects, defined here as entities to which harmful consequences are conceptually attached, were constructed differently by patients and GPs, especially in relation to cardiovascular risks. Their different rationalities sometimes obstructed any form of mutual risk-assessments. The relational theory of risk proved to be a useful theoretical frame for exploring layers and configurations of risk constructions among patients and clinicians, and for capturing interactional factors that support and obstruct mutual risk-assessments and SDM.

Practice implications: For patients to be able to engage in genuine dialogues and make informed decisions about their care, it is paramount for patients and doctors to co-construct patients’ health-risks during clinical encounters. 

B. Modes of interaction

(3) Lian OS, Nettleton S, Wifstad Å and Dowrick C (2021) Modes of interaction in naturally occurring medical encounters with general practitioners: The ´One in a Million´ study. Qualitative Health Research 31(6): 1129-1143. https://doi.org/10.1177/1049732321993790.

Study design: In this article, we qualitatively explore the manner and style in which medical encounters between patients and general practitioners (GPs) are mutually conducted, as exhibited in situ in 10 consultations sourced from the One in a Million: Primary Care Consultations Archive in England. Our main objectives are to identify interactional modes, to develop a classification of these modes, and to uncover how modes emerge and shift both within and between consultations.

Main findings: Deploying an interactional perspective and a thematic and narrative analysis of consultation transcripts, we identified five distinctive interactional modes: question and answer (Q&A) mode, lecture mode, probabilistic mode, competition mode, and narrative mode. Most modes are GP-led. Mode shifts within consultations generally map on to the chronology of the medical encounter. Patient-led narrative modes are initiated by patients themselves, which demonstrates agency. Our classification of modes derives from complete naturally occurring consultations, covering a wide range of symptoms, and may have general applicability.

(4) Lian OS, Nettleton S, Grange H and Dowrick C (2023) "It feels like my metabolism has shut down". Negotiating interactional roles and epistemic positions in a primary care consultation. Health Expectations 26(1): 366-375. https://onlinelibrary.wiley.com/doi/10.1111/hex.13666.

Introduction: Our aim is to explore the ways in which a patient and a general practitioner (GP) negotiate knowledge claims stemming from different epistemic domains while dealing with a mismatch between experiential and biomedical knowledge during the clinical consultation. We interpret their interaction in relation to the sociocultural context in which their negotiation is embedded and identify factors facilitating their successful negotiation (a medical error is avoided).

Methods: Based on a narrative analysis of a verbatim transcript of a complete naturally occurring primary care consultation, we explore the moment‐to‐moment unfolding of talk between the patient and the GP (two women).

Main findings: The patient experiences symptoms of what she interprets as a thyroid condition, and indirectly asks for medication. She presents her case by drawing on experiential knowledge (‘it feels like my metabolism has shut down’) and biomedical knowledge (while suggesting a diagnosis and a diagnostic test). The GP informs her that her thyroid blood tests are normal and uses biomedical knowledge to explain why she turns down the patient's request. This stages a potential conflict between the patient's embodied experiential knowledge and the doctor's biomedical knowledge. However, during their encounter, the patient and the GP manage to co‐construct the patient's illness story and make shared decisions about further actions.

Conclusion: The transition from potential conflict to consensus is a result of the mutual efforts of two parties: a patient who persistently claims experiential as well as biomedical knowledge while at the same time deferring to the GP's professional knowledge, and a GP who maintains her epistemic authority while also acknowledging the patient's experiential and biomedical knowledge.

C. Patient agency

(5) Lian OS, Nettleton S, Grange H and Dowrick C (2022) “I’m not the doctor; I’m just the patient”: Patient agency and shared decision-making in naturally occurring primary care consultations. Patient Education and Counceling 105(7): 1996-2004. https://doi.org/10.1016/j.pec.2021.10.031.

Objectives: To explore interactional processes in which clinical decisions are made in situ during medical consultations, particularly the ways in which patients show agency in decision-making processes by proposing and opposing actions, and which normative dimensions and role-expectations their engagement entail.

Methods: Narrative analysis of verbatim transcripts of 22 naturally occurring consultations, sourced from a corpus of 212 consultations between general practitioners and patients in England. After thematically coding the whole dataset, we selected 22 consultations with particularly engaged patients for in-depth analysis.

Main findings: Patients oppose further actions more often than they propose actions, and they oppose more directly than they propose. When they explain why they propose and oppose something, they reveal their values. Patients’ role-performance changes throughout the consultations.

Conclusion: Assertive patients claim – and probably also achieve – most influence when they oppose actions directly and elaborate why. Patients display ambiguous role-expectations. In final concluding stages of decision-making processes, patients usually defer to GPs’ authority.

Practice implications: Clinicians should be attentive to the ways in which patients want to engage in decision-making throughout the whole consultation, with awareness of normative dimensions of both process and content, and the ways in which patient’s actions are constrained by their institutional position.

(6) Lian OS, Nettleton S, Grange H and Dowrick C (2023) "My cousin said to me ..." Patients’ use of 3rd-party references to facilitate shared decision-making during naturally occurring primary care consultations. Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine. https://journals.sagepub.com/doi/10.1177/13634593231188489

Study design: In this paper, we explore the ways in which patients invoke 3rd parties to gain decision-making influence in clinical consultations. The patients’ role in decision-making processes is often overlooked, and this interactional practice has rarely been systematically studied. Through a contextual narrative exploration of 42 naturally occurring consultations between patients (aged 22-84) and general practitioners (GPs) in England, we seek to fill this gap. By exploring how and why patients invoke 3rd parties during discussions about medical tests and treatments, who they refer to, what kind of knowledge their referents possess, and how GPs respond, our main aim is to capture the functions and implications of this interactional practice in relation to decision-making processes. 

Main findings: Patients refer to 3rd parties during decision-making processes in most of the consultations, usually to argue for and against certain treatment options, and the GPs recognise these utterances as pro-and-contra arguments. This enables patients to counter the GPs’ professional knowledge through various knowledge-sources and encourage the GPs to target their specific concerns. By attributing arguments to 3rd parties, patients claim decision-making influence without threatening the GPs’ authority and expertise, which their disadvantaged epistemic position demands. Thereby, patients become able to negotiate their role and their epistemic position, to influence the agenda-setting, and to take part in the decision-making process, without being directly confrontational. Invoking 3rd parties is a non-confrontational way of proposing and opposing treatment options that might facilitate successful patient participation in decision-making processes, and so limit the risk of patients being wronged in their capacity as knowers.