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.

Indiana University-Purdue University Indianapolis (IUPUI) / In relationship-centered care, the relationship formed between physician and patient is critical to the creation of positive patient outcomes and patient satisfaction (Inui, 1996; Laine & Davidoff, 1996; Tresolini, 1994). Medical educators have increasingly utilized Objective Structured Clinical Examinations (OSCEs) to assess medical students’ abilities to utilize a relationship-centered approach in clinical interviewing. OSCEs, however, have recently come under scrutiny as critics contend that the overly scripted and standardized nature of the OSCE may not accurately reflect how medical students build and maintain relationships with patients. Although some studies have looked at how standardized patients help teach medical students interviewing skills, few studies have looked specifically at how the structured nature of the OSCE may influence relationship-building between standardized patients and medical students. Therefore, this study asks the question “How is relationship-centered care negotiated between standardized patients and medical students during a summative diagnostic OSCE?” Using an ethnographic methodology (Bochner & Ellis, 1996), data consists of an ethnographic field journal, transcripts of semi-structured interviews with SPs and medical students, and transcripts of headache and chronic cough videotaped scenarios. Using grounded theory (Strauss & Corbin, 1990, 1998), a back-and-forth thematic analysis was conducted in discovering the saturation of conceptual categories, linking relationships, and in critically comparing interpretive categorical concepts with relevant literature (Josselson & Leeblich, 1999). Findings suggest that standardized patients and medical students hold differing expectations for 1) diagnostic information gathering and 2) making personal connections upon entering a diagnostic summative OSCE. SPs “open up” both verbally and nonverbally when medical students “go beyond the checklist” by asking discrete diagnostic questions and when overtly trying to connect emotionally. Fourth year medical students, however, expect SPs to “open-up” during what they experience as a rushed, time-constrained, and overly structured “gaming” exercise which contradicts their own clinical experiences in being more improvisational during empathetic rapport building. Differences between SPs and medical students’ expectations and communication practices influence how they perform during summative diagnostic OSCEs. Findings may suggest the re-introduction of more relationship-focused OSCEs which positions SPs as proactive patients who reflexively co-teach students about the importance of making personal connections.

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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Prescription drug abuse is a public health problem of epidemic proportions in the United States. Provider-patient communication underpins many initiatives aimed at preventing and reducing the public health burden of prescription drug abuse. The characteristics of and factors contributing to this interpersonal process, however, have not been fully explored. The purpose of this research was to examine: 1) the overall problem of prescription drug abuse and provider-patient communication about prescription drug abuse from the patient perspective; and 2) provider-patient communication about prescription drug abuse from the prescriber perspective. In 2014-2015, semi-structured interviews were conducted with 20 patients from primary care and addiction medicine and 10 prescribers from multiple health professions and medical fields in Central and South Central Appalachia. The interviews were audio-recorded and transcribed verbatim. Thematic analysis, facilitated by qualitative data analysis software, was used to generate themes. Patients perceived prescription drug abuse as a problem, both in terms of its prevalence and contribution to negative consequences. Patients connected abuse to accessibility, identifying routes of access, routine practices, and rationales involved in the acquisition and distribution of prescription drugs for abuse. With regard to provider-patient communication, patients reported different levels of engagement in prescription drug abuse-related communication with healthcare providers—active, passive, and no/limited. Prescribers likewise reported different patterns of prescription drug abuse-related communication with patients—informative, counteractive, and supportive. Collectively, patients and prescribers described a range of factors—personal and environmental—that positively and negatively influence provider-patient communication and, by association, prescriber delivery and patient receipt of healthcare related to prescription drug abuse. When comparing the perspectives of patients and prescribers, multiple similarities in their prescription drug abuse-related communication perceptions and behaviors were identified. The findings of this research have implications for: 1) clinical practice to mitigate prescription drug abuse and improve patient prescription drug abuse-related communication behaviors; 2) patient- and prescriber-targeted interventions to improve provider-patient communication about prescription drug abuse; and 3) future research to continue to advance understanding of provider-patient communication about prescription drug abuse.

OBJECTIVES: Tools are needed for determining appropriate weights for complex performance assessment components in medical education. The feasibility of using judgmental policy capturing (JPC), a procedure to statistically describe the information processing strategies of experts, for this purpose was investigated. METHODS: Iterative JPC was used to determine appropriate weighting for the six core communication skill scores from a communications objective structured clinical examination (OSCE) for medical students using a panel of four communication skill experts. RESULTS: The mean regression weights from the panel indicated they placed less importance on information management (8.5%), moderate and nearly equal importance on rapport building (15.8%), agenda setting (15.4%), and addressing feelings (14.1%), and greater importance on active listening (20.1%) and reaching common ground with the patient (25.5%). DISCUSSION: JPC is an effective procedure for determining appropriate weights for complex clinical assessment components. The derived weights may be very different for those assessment components.

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