This study explores the experiences of General Practitioners (GPs) and patients in the management of type 2 diabetes in contemporary Australia. I focus on the way the socioeconomic position of patients is a factor in that experience as my underlying interest is in exploring how health inequalities are understood, approached and handled in general practice. The study is thus a practical and grounded exploration of a widely debated theoretical issue in the study of social life, namely the relationship between the micro day-to-day interactions and events in the lives of individuals and the broad macro structure of society and the position of the individual within that. There is now wide acceptance and evidence that people’s social and economic circumstances impact on their health status and their experiences in the health system. However, there is considerable debate about the role played by primary medical care. Nevertheless, better theoretical understanding of the importance of psychosocial processes in generating social inequalities in health suggests medical care may well be important, as such processes are crucial in the care of chronic illnesses such as diabetes which are now such a large part of general practice work. I approach this study through an exploration of patient centred clinical practice. Patient centredness is a pragmatic, idealised prescriptive framework for clinical practice, particularly general practice. Patient centredness developed in part in response to critiques of biomedicine, and is premised on a notion of a more equal relationship between GP and patient, and one that places importance on the context of patients’ lives. It contains an implicit promise that it will help GP and patient engage with and confront social disadvantage.

Working at the intersection of medical sociology and the psychology of health, language and communication, in this PhD I use thematic analysis (TA) and conversation analysis (CA) to provide an insight into various aspects of doctor-patient communication that may be considered, or are constructed as, challenging and/or delicate for either the patient, doctor or both at a Gender Identity Clinic (GIC) in the UK. This project involves the secondary analysis of two existing data-sets: (i) 21 recorded telephone interviews between my PhD supervisor and transsexual patients who attended the GIC; (ii) 156 transcribed audio-recordings and 38 video-recordings (total = 194) of psychiatrist-patient consultations in the GIC. The first original research paper uses TA to investigate the views and experiences of transsexual patients regarding their communication with psychiatrists at the GIC. An important finding was that patients actually appreciated being challenged in this setting, subsequently the implications of this are considered with regards to the achievability and desirability of patient centred communication. The second research paper uses CA to consider how patients overtly challenge psychiatrists in the GIC in ways that have not been shown in conversation analytic research on medical interactions to date. Analysis of the data corpus revealed that there were three common ways in which patients challenged psychiatrists at the GIC, which are (1) by problematising their questions; (2) by disagreeing with statements that are made regarding their treatment; (3) and by initiating complaints. The findings of this study are considered in relation to the implications that they have for clinicians and for the persistence and desirability of asymmetry in clinical interaction in light of the current debates surrounding the concept of patient-centeredness. The final research paper also uses CA, in this instance to study how the topic of weight, which is often constructed and orientated towards as delicate in talk-in-interaction, is occasioned and discussed by psychiatrists and patients at the GIC. Whereas previous CA research on this topic has focused on how this is constructed by speakers as a moral issue, this paper is concerned with focusing on how psychiatrists (1) establish with patients that their weight is an issue, (2) encourage patients to lose weight by informing them that this is their responsibility and (3) offer advice on the behavior changes associated with weight loss. The results of this paper are discussed with regards to the implications that they have for clinicians who discuss the potentially delicate topic of weight with patients in a number of different settings. This project contributes towards the growing debates regarding the achievability and desirability of patient centred communication and the persistence of asymmetry in clinical interaction. It also contributes to medical conversation analytic literature to date on asymmetry and talk about weight in clinical interactions.

The study of communication was born with the study of rhetoric, and scholars have been examining the creation and reception of messages for thousands of years. However, the term rhetoric often has negative connotations, as we hear people label some statement as “just rhetoric” or we hear them say, “The action doesn't match the rhetoric.” However, rhetoric is a style of communication that takes into account the effective use of both verbal and non-verbal languages, and it is one of the main ingredients in the day to day communication in organizations, healthcare organizations being no exception. It is virtually impossible to communicate without the use of rhetoric. This study focused on healthcare organizations because the delivery of healthcare is built on communication, and there is more to understand about the usage of language and organizational rhetoric in healthcare organizations. To these effects, the study examined communication in healthcare organizations and the perceived use of rhetoric among healthcare professionals; it explored how healthcare professionals perceive communication with their audiences, how the use of rhetoric, as perceived by healthcare professionals, affects communication in healthcare organizations and the contribution of rhetoric, as perceived by healthcare professionals, in motivating healthcare audience in healthcare organizations. The five canons of rhetoric were employed as a theoretical framework, and semi-structured interviews were used as tools for data collection. While contributing to existing literature on health and organizational communication, this study will also contribute in providing both government and private organizations insights into the use of rhetoric in professional communication with the hope of enhancing the quality of communication in the workplace.

Indiana University-Purdue University Indianapolis (IUPUI) / The treatment of chronic diseases requires patient adherence to medical advice. Nonadherence worsens health outcomes and increases healthcare costs. Consultations with a virtual physician could increase adherence, given the shortage of healthcare professionals. However, if the virtual physician is a computer animation, acceptance of its advice may be hampered by the uncanny valley effect, a negative affective reaction to human simulations. Two experiments were conducted to investigate the impact of the virtual physician on patients’ adherence. The first study, a 2 ´ 2 ´ 2 between-groups posttestonly experiment, involved 738 participants playing the role of a patient in a hypothetical virtual consultation with a doctor. The consultation varied in the doctor’s Character, Outcome, and Depiction. Character, Outcome, and Depiction were designed to manipulate the doctor’s level of warmth, competence, and realism. The second study, a 2 ´ 5 between-groups experiment, involved 441 participants assuming a patient’s role in a similar hypothetical virtual consultation with a doctor. The experiment varied the doctor’s Character and Depiction. These independent variables were designed to manipulate the doctor’s level of warmth and eeriness. The first study found that warmth and competence increased adherence intention and consultation enjoyment, but realism did not. On the contrary, the computer-animated doctor increased adherence intention and consultation enjoyment significantly more than the doctor portrayed by a human actor. The enjoyment of the animated consultation caused the doctor to appear warmer and more real, compensating for his realism inconsistency. In the second study, Depiction had a nonsignificant effect on adherence intention, even though the computer animated doctor was perceived as eerier than the real human. The low-warmth, high-eeriness doctor prompted heuristic processing of information, while the high-warmth doctor prompted systematic processing. This pattern runs counter to the literature on persuasion. The doctor’s eeriness, measured in a pretest, had no significant effect on adherence intention via the heuristic-systematic model. Although virtual characters can elicit the uncanny valley effect, they were comparable to a real person in increasing adherence intention, adherence and health behavior. This finding should encourage the development and acceptance of virtual consultation to address the shortage of healthcare professionals. / 2023-11-03

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Made available in DSpace on 2015-03-05T18:11:56Z (GMT). No. of bitstreams: 0 Previous issue date: 19 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Este trabalho está vinculado a um projeto de pesquisa maior (OSTERMANN, 2005) que tem como objetivo analisar as interações entre médicos/as e pacientes que buscam atendimento ginecológico e obstétrico em um posto de saúde da região metropolitana de Porto Alegre, Brasil. A abordagem teórica e metodológica utilizada é a da Análise da Conversa (SACKS, 1992; WOOFFITT, 2005; HUTCHBY e WOOFFITT, 1998) e a da Sociolingüística Interacional (OSTERMANN, 2003; GUMPERZ, 1998; GOFFMAN, 1995), que propõem investigações de dados naturalísticos, os quais são, nesta pesquisa, 144 consultas médicas gravadas em áudio e transcritas de acordo com as convenções propostas por Jefferson (1984), além de anotações de observações sobre a instituição investigada. Este estudo investiga quais as identidades que emergem nas interações e como elas são negociadas pelos/as interagentes nos diferentes momentos das consultas (BUCHOLTZ, 1999; BUCHOLTZ e HALL, 2005; ECKERT e McCONNELL-GINET, 1992 e 2003; OSTERMANN, 2003 e 2006). Verificou-se que / This paper draws from a larger research project (OSTERMANN, 2005) that aims at investigating how doctors and patients, who seek gynecological and obstetrical consults in a public health center Southern Brazil interact. The theoretical and methodological approaches that underlie the research study are Conversation Analysis (SACKS, 1992; WOOFFITT, 2005; HUTCHBY e WOOFFITT, 1998) and Sociolinguistics (OSTERMANN, 2003; GUMPERZ, 1998; GOFFMAN, 1995), which propose investigations of naturalistic data. That data analyzed consists of 144 medical consultations recorded in audio and transcribed according to the conventions proposed by Jefferson (1984), as well as noted observations about the investigated institution. This study investigates which identities emerge in the interactions and how they are negotiated by the interactants during the different moments of the consultations (BUCHOLTZ, 1999; BUCHOLTZ e HALL, 2005; ECKERT e McCONNELL-GINET, 1992 e 2003; OSTERMANN, 2003 e 2006). It was verified that different identi

Submitted by Maicon Juliano Schmidt (maicons) on 2015-05-26T14:11:20Z No. of bitstreams: 1 Joseane de Souza.pdf: 968658 bytes, checksum: 829b2d7efae01f53c4f417cbdf44f8eb (MD5) / Made available in DSpace on 2015-05-26T14:11:20Z (GMT). No. of bitstreams: 1 Joseane de Souza.pdf: 968658 bytes, checksum: 829b2d7efae01f53c4f417cbdf44f8eb (MD5) Previous issue date: 2015-03-31 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Esta tese provém de uma pesquisa de doutorado em Linguística Aplicada que visa a entender como se dão as interações entre oncologistas e mulheres com câncer de mama em consultas de acompanhamento ao longo de seus tratamentos ou de revisão. O foco do estudo foi em atendimentos que não consistiam em comunicação de más notícias (uma vez que as pacientes já haviam passado pelo diagnóstico de câncer) nem em tratamento de pacientes terminais. A literatura a respeito da relação médico-paciente no câncer tem englobado largamente esses dois pontos. Entretanto, a preocupação com a interação em consultas mais rotineiras, durante os tratamentos e nas revisões periódicas, em que nenhum diagnóstico ou prognóstico negativo é de fato entregue pelo médico, ainda é escassa. A metodologia utilizada advém da abordagem teórico-metodológica da Análise da Conversa ou Fala-em-Interação (SACKS, 1992; OSTERMANN; MENEGHEL, 2012). Seu foco é a observação, gravação em áudio (podendo ser também em vídeo) e posterior descrição das interações, das características das ações que os participantes ali produzem e de como as ações de um interagente afetam o outro, que irá produzir suas ações em resposta. Os dados (24 consultas gravadas em áudio) foram coletados em um hospital da região sul do Brasil que possui um centro para tratamento de câncer, transcritos segundo convenções próprias da área (JEFFERSON, 1984) e então analisados. A partir das análises, são descritas ações recorrentes realizadas por oncologistas e pacientes, tais como solicitações de avaliação; avaliações do próprio estado emocional; avaliações de estado físico; recomendações e avaliações prognósticas com justificativas e argumentação; accounts. Essas ações interacionais revelam que os participantes estão a lidar com a impossibilidade da certeza em vários aspectos nas consultas; por exemplo: a impossibilidade de uma avaliação prognóstica absolutamente certa, a impossibilidade de certeza sobre estar-se livre de recidivas, a impossibilidade de certeza de que determinados testes realmente servirão de base para as tomadas de decisão necessárias, etc. Além disso, algumas ações dos médicos (avaliações positivas, recomendações e avaliações prognósticas com justificativas e argumentação e accounts) possuem um potencial de tranquilização da paciente ao poderem diminuir incertezas por meio da construção de uma maior assertividade. Ao final, a contribuição do estudo pode consistir no aprimoramento de um dos eixos básicos da relação médico-paciente: como humanizar a relação oncologista-paciente de câncer de mama por meio de um aparato comunicacional – as práticas interacionais de gerenciamento da certeza. / The present dissertation derives from doctoral research in Applied Linguistics that aims at understanding how interactions between oncologists and women with breast cancer play out in long-term treatment consultations and/or follow-up ones. The focus of the study was neither on consultations where bad news was delivered (since the patients had already been diagnosed with the illness) nor on those with terminally ill patients. Literature on the doctor-patient relationship in cancer has largely covered these issues. However, concern about verbal interaction in routine consultations during treatment and in periodic revisions, during which no diagnosis or negative prognosis is actually delivered by the doctor, has been scarce. The methodology used originates in the theoretical-methodological approach of Conversation Analysis or talk-in-interaction (SACKS, 1992; OSTERMANN; MENEGHEL, 2012). Its goal is the observation, audio (or video) recording and latter description of the interactions, the characteristics of the actions the participants produce therein and how one party’s actions affect the other, who will, in turn, produce his/her action in response. The data (24 audio recordings) were collected in a hospital in southern Brazil which is equipped with a cancer treatment center, then transcribed in accordance with conventions used in the field (JEFFERSON, 1984), then analyzed. From the analyses, recurring actions performed by doctors and their patients are described, such as requests for assessments; self-assessments of a patient’s emotional state; physical assessments; recommendations and prognostic evaluations with justifications and argumentation; accounts. These interactional actions show that the participants are dealing with a situation in which certainty is impossible in various aspects of the consultations, for instance: the impossibility of an absolutely certain prognostic evaluation, the impossibility of being sure about not having a relapse, the impossibility of certainty with regard to whether certain tests will actually serve as a basis for making necessary decisions, etc. Furthermore, some of these actions by the doctor (positive assessments, recommendations and prognostic assessments with justifications and argumentation, and accounts) have the potential to reassure the patient as they can reduce uncertainty by means of the construction of assertiveness. Ultimately, the contribution of this study may lie in the improvement of one of the basic axes of the relationship between doctors and their patients: how to humanize the oncologist-breast cancer patient relationship by means of a communicational apparatus – the interactional practices of certainty management.

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Research shows that health disparities exist among patients of varying races, ethnicities, and cultures in the United States. Numerous studies have suggested that these disparities may be partly associated with physician-patient communication. The larger project that this thesis is a part of is a mixed-methods analysis of physician-patient communication across patient race, ethnicity, and culture. This thesis specifically excluded qualitative studies and focused on how such communication can affect health outcomes. Sixty-nine studies were identified and appraised for quality. Of these, only four associated physician-patient communication with the health outcomes of patients. These studies had inconsistent results, highlighting the gap in research exploring the association between communication, patient ethnicity, and health outcomes.

Effective doctor-patient communication is critical to improving health outcomes. Good communication improves emotional health, symptom resolution, functional and physiologic status, and pain control. Conversely, ineffective communication leads to misdiagnosis, inappropriate treatment poor adherence, misuse of health services, and high patient stress. In the U.S., Hispanics are the fastest growing minority. Despite the high burden of illness among this population, Hispanics are less likely than other minorities to regularly see a health professional. This is explained in part because Hispanics navigate a health system designed for the majority, experience a mismatch between cultural values and health beliefs, and have limited English proficiency. These communication challenges contribute to health disparities among the Hispanic population living in the U.S. Despite the importance of doctor-patient communication, few communication interventions that focus on improving patient skills have been tested in this population. Therefore, the purpose of this study was to evaluate whether a patient communication intervention tailored for female Hispanic patients could be practically implemented in a practice setting. The first aim focused on adapting existing communication skills training tools for a Hispanic population. The second aim assessed the feasibility of implementing the training tool in a federally qualified health center in a US-Mexico border community. The third aim explored the extent to which trained patients were able to integrate the information provided. Results indicate that it is feasible to implement communication training when delivered by clinical staff. Patient follow-up revealed that patients valued training on how to communicate with their doctor the most. Moreover, it is feasible to sustain the intervention when it is aligned with the priorities of the clinical site. Patient communication training in medically underserved rural areas could improve barriers to improved health outcomes in communities with a high prevalence of Hispanic patients. Future funding is needed to further test, dissemination of communication training programs.