Alexandra Tate | University of Chicago (original) (raw)
Papers and book chapters by Alexandra Tate
Social Science and Medicine, 2022
Care at the end-of-life in the United States has expanded in the past decade in large part due to... more Care at the end-of-life in the United States has expanded in the past decade in large part due to structural changes such as increased access to hospice care, the integration of palliative care, policy mandates, and financial incentives. Despite these shifts, research shows that appropriate end-of-life care continues to be underutilized. This paper uses conversation analytic (CA) and ethnographic methods to examine doctor-patient interactions among a sample of 14 Stage IV cancer patients and the way decisions unfold about next steps in treatment during a moment that larger policy changes began to take place following passage of the Affordable Care Act. This work reveals that, despite structures designed to better facilitate end-of-life care transitions for patients in late life, doctors continue to demonstrate interactional hesitancy in discussing the possibility of a patient's end-of-life in treatment discussions and an orientation to the treatment imperative. Examining doctor-patient interaction as one key trouble source in end-of-life care implementation shows in situ evidence that the treatment imperative supersedes the structural shifts supporting less medical intervention in late life.
Social Science and Medicine, 2020
Existing sociological research documents patient and physician reticence to discuss death in the ... more Existing sociological research documents patient and physician reticence to discuss death in the context of a
patient's end of life. This study offers a new approach to analyzing how death gets discussed in medical interaction.
Using a corpus of 90 video-recorded oncology visits and conversation analytic (CA) methods, this analysis
reveals that when existing parameters are expanded to look at mentions of death outside of the end-of-life
context, physicians do discuss death with their patients. Specifically, the most frequent way physicians invoke
death is in a persuasive context during treatment recommendation discussions. When patients demonstrate
active or passive resistance to a recommendation, physicians invoke the possibility of the patient's death to push
back against this resistance and lobby for treatment. Occasionally, physicians invoke death in instances where
resistance is anticipated but never actualized. Similarly, death invocations function for treatment advocacy.
Ultimately, this study concludes that physicians in these data invoke death to leverage their professional authority
for particular treatment outcomes.
Patient Education and Counseling, 2019
Objective: Listing more than one option for treatment, termed "option-listing" (OL) is one way to... more Objective: Listing more than one option for treatment, termed "option-listing" (OL) is one way to facilitate shared decision-making. We seek to evaluate how oncologists do option-listing in clinical encounters across disease contexts. Method: We coded and transcribed 90 video-recorded interactions between 5 oncologist participants and a convenience sample of 82 patients at 2 large clinics in the western U.S. We used conversation analytic (CA) methods to examine patterns of behavior when oncologists provided more than one treatment option to patients. Results: In early-stage disease, OL provides patients with options while at the same time constraining those options through expression of physician bias. This effect disappears when cancer is at an advanced stage. In this context, OL is presented without physician preference and demonstrates recission of medical authority. Conclusion: In early-stage contexts, OL functions as a way for physicians to array available options to patients while also communicating their expertise. In advanced-stage contexts, OL functions as a way to minimize treatment options and highlight dwindling possibilities. Practice implications: OL is one way to implement shared decision-making, but it can also be used to facilitate a realization that treatment choices are diminishing and disease is progressing beyond a cure.
Research in the Sociology of Health Care, 2018
Purpose: Encouraging patient involvement is a cornerstone of many healthcare interventions and de... more Purpose: Encouraging patient involvement is a cornerstone of many
healthcare interventions and decision-making models to ensure that treatment decisions reflect the needs, values, and desires of patients. Involved patients are thought to be empowered patients who feel a sense of efficacy in regards to their own health. However, there is a lack of understanding of how patients relate to empowerment and involvement and, most importantly, how these
constructs relate to one another in patients’ decision-making experiences.
Methodology/approach: Through an inductive analysis, this chapter
draws on qualitative interviews of women diagnosed with breast cancer prior to 40 years of age (n=69).
Findings : By examining the intersection of how patients define their own
involvement in treatment decisions and their sense of empowerment, we find four orientations to decision-making (Advocates, Bystanders, Co-Pilots, and Downplayers) with involvement and empowerment being coupled for some respondents, but decoupled for others.
Research limitations/implications: Our findings suggest expanding what it means to be an “active” patient as respondents had multiple ways of
characterizing involvement, including being informed or following their
doctor’s advice. Our findings also suggest a more critical examination of the origins and potential downsides of patient empowerment as some respondents reported feeling overwhelmed or pushed into advocacy roles. The sample was disproportionately higher socioeconomic status with limited racial/ethnic diversity. Empowerment and involvement may be enacted differently for other social groups and other medical conditions.
Originality/value: By examining first-person patient narratives, we
conclude that patients’ experience may not fully align with current academic or clinical discussions of patient involvement or empowerment.
Health Communication, 2019
Although oncology is a major site for clinician‒patient treatment negotiation requiring a careful... more Although oncology is a major site for clinician‒patient treatment negotiation requiring a careful balance of potentially competing viewpoints, little is known about how clinicians promote their treatment recommendations to patients and what the manner of promotion tells us about the oncologist‒patient relationship. Utilizing an already-established schema of coding treatment recommendations, I draw on 61 treatment recommendations to examine treatment decision-making in oncology. This paper inves- tigates how physicians balance asserting their authority while at the same time attending to patient agency and involvement in decision-making. Taking this one step further, this paper explores how physicians negotiate decision-making with patients given that they occupy a liminal state between obligations to policy imperatives and commitments to their professional knowledge and technical expertise. How do they do this, and what accounts for this? To answer these questions, this paper analyzes the ways in which physicians present treatment recommendations and the treatment contexts in which they are made.
Patient education and counseling, Jan 21, 2015
Soliciting patients' complete agendas of concerns (aka. 'agenda setting') can improve... more Soliciting patients' complete agendas of concerns (aka. 'agenda setting') can improve patients' health outcomes and satisfaction, and physicians' time management. We assess the distribution, content, and effectiveness of physicians' post-chief-complaint, agenda-setting questions. We coded videotapes/transcripts of 407 primary-, acute-care visits between adults and 85 general-practice physicians operating in 46 community-based clinics in two states representing urban and rural care. Measures are the incidence of physicians' questions, their linguistic format, position within visits, likelihood of being responded to, and the nature of such responses. Physicians' questions designed to solicit concerns additional to chief concerns occurred in only 32% of visits (p<.001). Compared to questions whose communication format explicitly solicited 'questions' (e.g., "Do you have any questions?"), those that were formatted so as to allow for &...
Journal of Family Planning and Reproductive Health Care, Jan 30, 2013
OBJECTIVES: There has been increased attention paid to cancer-related infertility and fertility p... more OBJECTIVES: There has been increased attention paid to cancer-related infertility and fertility preservation. However, how cancer patients decide whether or not to pursue fertility preservation has not been fully examined.METHODS: The data come from 34 interviews with women in the USA diagnosed with breast cancer prior to 40 years of age who contemplated fertility preservation prior to cancer treatment. Fully transcribed interviews were coded through a three-staged inductive process.RESULTS: Three sets of factors that shaped the decision-making process of the respondents regarding fertility preservation treatment options were identified: perceived benefits (e.g. ability to use 'younger' eggs in the future), inhibiting concerns (e.g. success rates) and influential relationships (e.g. physicians, parents and partners).CONCLUSIONS: Respondents saw their main fertility preservation decision as choosing whether or not to pursue egg/embryo banking. The decision-making process was complicated and included both health-related and personal considerations, with many respondents reporting a lack of support services for fertility issues. Findings suggest that greater attention needs to be placed on presenting patients with a wider range of options. Those who counsel patients regarding fertility preservation decisions should be aware of the influence of relationship dynamics, broader health care concerns, and fertility histories on these decisions.
Papers by Alexandra Tate
Annual Review of Linguistics
The physician–patient relationship has evolved significantly in the past century. Physician autho... more The physician–patient relationship has evolved significantly in the past century. Physician authority has been reduced while patients have been empowered. This review focuses on face-to-face clinical care and argues that current physician–patient relations range from partnerships between social actors who each play critical roles in negotiating care to a more adversarial duel in which both participants advocate for goals that are not necessarily shared. While the former is the hope of increased patient involvement, the latter is increasingly common. Through our discussion of existing studies, we document that while high levels of patient participation are beneficial to treatment outcomes, this engagement also has a dark side that threatens treatment outcomes. We discuss some communication resources patients use that affect treatment outcomes, exemplify how patient engagement affects physician communication, and discuss some strategies that current research finds effective for commun...
Social Science & Medicine
Care at the end-of-life in the United States has expanded in the past decade in large part due to... more Care at the end-of-life in the United States has expanded in the past decade in large part due to structural changes such as increased access to hospice care, the integration of palliative care, policy mandates, and financial incentives. Despite these shifts, research shows that appropriate end-of-life care continues to be underutilized. This paper uses conversation analytic (CA) and ethnographic methods to examine doctor-patient interactions among a sample of 14 Stage IV cancer patients and the way decisions unfold about next steps in treatment during a moment that larger policy changes began to take place following passage of the Affordable Care Act. This work reveals that, despite structures designed to better facilitate end-of-life care transitions for patients in late life, doctors continue to demonstrate interactional hesitancy in discussing the possibility of a patient's end-of-life in treatment discussions and an orientation to the treatment imperative. Examining doctor-patient interaction as one key trouble source in end-of-life care implementation shows in situ evidence that the treatment imperative supersedes the structural shifts supporting less medical intervention in late life.
Author(s): Tate, Alexandra | Advisor(s): Stivers, Tanya | Abstract: Situated in the domain of the... more Author(s): Tate, Alexandra | Advisor(s): Stivers, Tanya | Abstract: Situated in the domain of the cancer clinic, this dissertation uses conversation analytic and ethnographic approaches to explore the ways in which patient involvement and physician expertise are negotiated in an age of evidence-based medicine, decreased medical authority, and increased patient agency and autonomy under the tenants of shared decision-making. Although cancer care is a major site for clinician-patient treatment negotiation requiring a careful balance of potentially competing viewpoints, little is known about how clinicians promote their treatment recommendations to patients, what the manner of promotion tells us about the oncologist-patient relationship, and how clinicians respond when patients resist their treatment recommendations. Drawing on video-recorded encounters between oncologists and their patients, this analysis examines treatment decision-making in oncology and investigates how physicians b...
Social Science & Medicine, 2019
Existing sociological research documents patient and physician reticence to discuss death in the ... more Existing sociological research documents patient and physician reticence to discuss death in the context of a patient's end of life. This study offers a new approach to analyzing how death gets discussed in medical interaction. Using a corpus of 90 video-recorded oncology visits and conversation analytic (CA) methods, this analysis reveals that when existing parameters are expanded to look at mentions of death outside of the end-of-life context, physicians do discuss death with their patients. Specifically, the most frequent way physicians invoke death is in a persuasive context during treatment recommendation discussions. When patients demonstrate active or passive resistance to a recommendation, physicians invoke the possibility of the patient's death to push back against this resistance and lobby for treatment. Occasionally, physicians invoke death in instances where resistance is anticipated but never actualized. Similarly, death invocations function for treatment advocacy. Ultimately, this study concludes that physicians in these data invoke death to leverage their professional authority for particular treatment outcomes.
Patient Education and Counseling, 2019
Health Communication, 2018
Although oncology is a major site for clinician-patient treatment negotiation requiring a careful... more Although oncology is a major site for clinician-patient treatment negotiation requiring a careful balance of potentially competing viewpoints, little is known about how clinicians promote their treatment recommendations to patients and what the manner of promotion tells us about the oncologist-patient relationship. Utilizing an already-established schema of coding treatment recommendation, I draw on 61 treatment recommendations to examine treatment decision-making in oncology. This paper investigates how physicians balance asserting their authority while at the same time attending to patient agency and involvement in decision-making. Taking this one step further, this paper explores how physicians negotiate decision-making with patients given that they occupy a liminal state between obligations to policy imperatives and commitments to their professional knowledge and technical expertise. How do they do this, and what accounts for this? To answer these questions, this paper analyzes the ways in which physicians present treatment recommendations and the treatment contexts in which they are made. A primary function of clinical consultations with ill patients is to identify an appropriate treatment. Physicians hold most of the cards in this situation: they have the knowledge to diagnose and to understand what the diagnostic implications are for treatment, and they possess the legal and cultural authority to prescribe (Stivers, 2002; Timmermans & Oh, 2010). Yet, a shift in patient-provider dynamics since the 1960s has provided patients with increasing power. The rise of patient consumerism and informed consent has reoriented the medical profession toward increased patient involvement (Jones, 2017). The increasing availability of health information on the internet has also facilitated increased patient involvement in their own health care (Boyer & Lutfey, 2010). Some have pointed out that a consequence of this is the "democratization" of health information through its availability to both laypeople and health-care professionals (Anspach, 2011). Moreover, patients are the practical gatekeepers of all actual treatment implementation insofar as they must ingest pills, show up for chemotherapy, etc. This yields an interdependent relationship between physician and patient, making treatment decision-making an exceptionally rich communicative environment for examining the delicate balance of patient and physician viewpoints in how decisions get made. This is particularly the case in oncology because treatments are complex and range from innocuous
Oncofertility Communication, 2013
A cancer diagnosis is a life-altering event and since cancer treatment can impair future fertilit... more A cancer diagnosis is a life-altering event and since cancer treatment can impair future fertility capacity, cancer can also change a patient’s parenting plans and family goals. There has been increased attention to the issue of cancer-related fertility impairment in recent years [1, 2], including the establishment of best practice guidelines from ASCO (American Society of Clinical Oncology) [3], ASRM (American Society for Reproductive Medicine) [4], and AAP (American Academy of Pediatrics) [5], as well as advocacy groups aimed at both patients and doctors to educate on the issue of fertility preservation (including Fertile Hope and the Oncofertility Consortium). There has even been increased coverage in entertainment and popular media on post-cancer parenthood, including notable high-profile cases such as Lance Armstrong. Despite these strides, there is continued concern that cancer patients are not always informed about potential impairment or available fertility preservation options that can help to safeguard their future fertility. Earlier studies in the growing field of oncofertility have indicated that many patients, particularly adolescent and pediatric patients [6], do not recall discussing fertility or fertility preservation options prior to beginning chemotherapy and/or radiation [1]. As a result, researchers are examining the barriers to the exchange of fertility-related discussions between patients and doctors (particularly oncologists) prior to potentially damaging cancer treatment (see [1] for review).
Journal of Family Planning and Reproductive Health Care, 2013
Objectives There has been increased attention paid to cancer-related infertility and fertility pr... more Objectives There has been increased attention paid to cancer-related infertility and fertility preservation. However, how cancer patients decide whether or not to pursue fertility preservation has not been fully examined. Methods The data come from 34 interviews with women in the USA diagnosed with breast cancer prior to 40 years of age who contemplated fertility preservation prior to cancer treatment. Fully transcribed interviews were coded through a three-staged inductive process. Results Three sets of factors that shaped the decision-making process of the respondents regarding fertility preservation treatment options were identified: perceived benefits (e.g. ability to use 'younger' eggs in the future), inhibiting concerns (e.g. success rates) and influential relationships (e.g. physicians, parents and partners). Conclusions Respondents saw their main fertility preservation decision as choosing whether or not to pursue egg/embryo banking. The decision-making process was complicated and included both health-related and personal considerations, with many respondents reporting a lack of support services for fertility issues. Findings suggest that greater attention needs to be placed on presenting patients with a wider range of options. Those who counsel patients regarding fertility preservation decisions should be aware of the influence of relationship dynamics, broader health care concerns, and fertility histories on these decisions.
Research in the Sociology of Health Care, 2018
Abstract Purpose Encouraging patient involvement is a cornerstone of many healthcare intervention... more Abstract Purpose Encouraging patient involvement is a cornerstone of many healthcare interventions and decision-making models to ensure that treatment decisions reflect the needs, values, and desires of patients. Involved patients are thought to be empowered patients who feel a sense of efficacy in regards to their own health. However, there is a lack of understanding of how patients relate to empowerment and involvement and, most importantly, how these constructs relate to one another in patients’ decision-making experiences. Methodology/approach Through an inductive analysis, this chapter draws on qualitative interviews of women diagnosed with breast cancer prior to 40 years of age (n = 69). Findings By examining the intersection of how patients define their own involvement in treatment decisions and their sense of empowerment, we find four orientations to decision-making (Advocates, Bystanders, Co-Pilots, and Downplayers) with involvement and empowerment being coupled for some respondents, but decoupled for others. Research limitations/implications Our findings suggest expanding what it means to be an “active” patient as respondents had multiple ways of characterizing involvement, including being informed or following their doctor’s advice. Our findings also suggest a more critical examination of the origins and potential downsides of patient empowerment as some respondents reported feeling overwhelmed or pushed into advocacy roles. The sample was disproportionately higher socioeconomic status with limited racial/ethnic diversity. Empowerment and involvement may be enacted differently for other social groups and other medical conditions. Originality/value By examining first-person patient narratives, we conclude that patients’ experience may not fully align with current academic or clinical discussions of patient involvement or empowerment.
Patient education and counseling, Jan 21, 2015
Soliciting patients' complete agendas of concerns (aka. 'agenda setting') can improve... more Soliciting patients' complete agendas of concerns (aka. 'agenda setting') can improve patients' health outcomes and satisfaction, and physicians' time management. We assess the distribution, content, and effectiveness of physicians' post-chief-complaint, agenda-setting questions. We coded videotapes/transcripts of 407 primary-, acute-care visits between adults and 85 general-practice physicians operating in 46 community-based clinics in two states representing urban and rural care. Measures are the incidence of physicians' questions, their linguistic format, position within visits, likelihood of being responded to, and the nature of such responses. Physicians' questions designed to solicit concerns additional to chief concerns occurred in only 32% of visits (p<.001). Compared to questions whose communication format explicitly solicited 'questions' (e.g., "Do you have any questions?"), those that were formatted so as to allow for &...
Social Science and Medicine, 2022
Care at the end-of-life in the United States has expanded in the past decade in large part due to... more Care at the end-of-life in the United States has expanded in the past decade in large part due to structural changes such as increased access to hospice care, the integration of palliative care, policy mandates, and financial incentives. Despite these shifts, research shows that appropriate end-of-life care continues to be underutilized. This paper uses conversation analytic (CA) and ethnographic methods to examine doctor-patient interactions among a sample of 14 Stage IV cancer patients and the way decisions unfold about next steps in treatment during a moment that larger policy changes began to take place following passage of the Affordable Care Act. This work reveals that, despite structures designed to better facilitate end-of-life care transitions for patients in late life, doctors continue to demonstrate interactional hesitancy in discussing the possibility of a patient's end-of-life in treatment discussions and an orientation to the treatment imperative. Examining doctor-patient interaction as one key trouble source in end-of-life care implementation shows in situ evidence that the treatment imperative supersedes the structural shifts supporting less medical intervention in late life.
Social Science and Medicine, 2020
Existing sociological research documents patient and physician reticence to discuss death in the ... more Existing sociological research documents patient and physician reticence to discuss death in the context of a
patient's end of life. This study offers a new approach to analyzing how death gets discussed in medical interaction.
Using a corpus of 90 video-recorded oncology visits and conversation analytic (CA) methods, this analysis
reveals that when existing parameters are expanded to look at mentions of death outside of the end-of-life
context, physicians do discuss death with their patients. Specifically, the most frequent way physicians invoke
death is in a persuasive context during treatment recommendation discussions. When patients demonstrate
active or passive resistance to a recommendation, physicians invoke the possibility of the patient's death to push
back against this resistance and lobby for treatment. Occasionally, physicians invoke death in instances where
resistance is anticipated but never actualized. Similarly, death invocations function for treatment advocacy.
Ultimately, this study concludes that physicians in these data invoke death to leverage their professional authority
for particular treatment outcomes.
Patient Education and Counseling, 2019
Objective: Listing more than one option for treatment, termed "option-listing" (OL) is one way to... more Objective: Listing more than one option for treatment, termed "option-listing" (OL) is one way to facilitate shared decision-making. We seek to evaluate how oncologists do option-listing in clinical encounters across disease contexts. Method: We coded and transcribed 90 video-recorded interactions between 5 oncologist participants and a convenience sample of 82 patients at 2 large clinics in the western U.S. We used conversation analytic (CA) methods to examine patterns of behavior when oncologists provided more than one treatment option to patients. Results: In early-stage disease, OL provides patients with options while at the same time constraining those options through expression of physician bias. This effect disappears when cancer is at an advanced stage. In this context, OL is presented without physician preference and demonstrates recission of medical authority. Conclusion: In early-stage contexts, OL functions as a way for physicians to array available options to patients while also communicating their expertise. In advanced-stage contexts, OL functions as a way to minimize treatment options and highlight dwindling possibilities. Practice implications: OL is one way to implement shared decision-making, but it can also be used to facilitate a realization that treatment choices are diminishing and disease is progressing beyond a cure.
Research in the Sociology of Health Care, 2018
Purpose: Encouraging patient involvement is a cornerstone of many healthcare interventions and de... more Purpose: Encouraging patient involvement is a cornerstone of many
healthcare interventions and decision-making models to ensure that treatment decisions reflect the needs, values, and desires of patients. Involved patients are thought to be empowered patients who feel a sense of efficacy in regards to their own health. However, there is a lack of understanding of how patients relate to empowerment and involvement and, most importantly, how these
constructs relate to one another in patients’ decision-making experiences.
Methodology/approach: Through an inductive analysis, this chapter
draws on qualitative interviews of women diagnosed with breast cancer prior to 40 years of age (n=69).
Findings : By examining the intersection of how patients define their own
involvement in treatment decisions and their sense of empowerment, we find four orientations to decision-making (Advocates, Bystanders, Co-Pilots, and Downplayers) with involvement and empowerment being coupled for some respondents, but decoupled for others.
Research limitations/implications: Our findings suggest expanding what it means to be an “active” patient as respondents had multiple ways of
characterizing involvement, including being informed or following their
doctor’s advice. Our findings also suggest a more critical examination of the origins and potential downsides of patient empowerment as some respondents reported feeling overwhelmed or pushed into advocacy roles. The sample was disproportionately higher socioeconomic status with limited racial/ethnic diversity. Empowerment and involvement may be enacted differently for other social groups and other medical conditions.
Originality/value: By examining first-person patient narratives, we
conclude that patients’ experience may not fully align with current academic or clinical discussions of patient involvement or empowerment.
Health Communication, 2019
Although oncology is a major site for clinician‒patient treatment negotiation requiring a careful... more Although oncology is a major site for clinician‒patient treatment negotiation requiring a careful balance of potentially competing viewpoints, little is known about how clinicians promote their treatment recommendations to patients and what the manner of promotion tells us about the oncologist‒patient relationship. Utilizing an already-established schema of coding treatment recommendations, I draw on 61 treatment recommendations to examine treatment decision-making in oncology. This paper inves- tigates how physicians balance asserting their authority while at the same time attending to patient agency and involvement in decision-making. Taking this one step further, this paper explores how physicians negotiate decision-making with patients given that they occupy a liminal state between obligations to policy imperatives and commitments to their professional knowledge and technical expertise. How do they do this, and what accounts for this? To answer these questions, this paper analyzes the ways in which physicians present treatment recommendations and the treatment contexts in which they are made.
Patient education and counseling, Jan 21, 2015
Soliciting patients' complete agendas of concerns (aka. 'agenda setting') can improve... more Soliciting patients' complete agendas of concerns (aka. 'agenda setting') can improve patients' health outcomes and satisfaction, and physicians' time management. We assess the distribution, content, and effectiveness of physicians' post-chief-complaint, agenda-setting questions. We coded videotapes/transcripts of 407 primary-, acute-care visits between adults and 85 general-practice physicians operating in 46 community-based clinics in two states representing urban and rural care. Measures are the incidence of physicians' questions, their linguistic format, position within visits, likelihood of being responded to, and the nature of such responses. Physicians' questions designed to solicit concerns additional to chief concerns occurred in only 32% of visits (p<.001). Compared to questions whose communication format explicitly solicited 'questions' (e.g., "Do you have any questions?"), those that were formatted so as to allow for &...
Journal of Family Planning and Reproductive Health Care, Jan 30, 2013
OBJECTIVES: There has been increased attention paid to cancer-related infertility and fertility p... more OBJECTIVES: There has been increased attention paid to cancer-related infertility and fertility preservation. However, how cancer patients decide whether or not to pursue fertility preservation has not been fully examined.METHODS: The data come from 34 interviews with women in the USA diagnosed with breast cancer prior to 40 years of age who contemplated fertility preservation prior to cancer treatment. Fully transcribed interviews were coded through a three-staged inductive process.RESULTS: Three sets of factors that shaped the decision-making process of the respondents regarding fertility preservation treatment options were identified: perceived benefits (e.g. ability to use 'younger' eggs in the future), inhibiting concerns (e.g. success rates) and influential relationships (e.g. physicians, parents and partners).CONCLUSIONS: Respondents saw their main fertility preservation decision as choosing whether or not to pursue egg/embryo banking. The decision-making process was complicated and included both health-related and personal considerations, with many respondents reporting a lack of support services for fertility issues. Findings suggest that greater attention needs to be placed on presenting patients with a wider range of options. Those who counsel patients regarding fertility preservation decisions should be aware of the influence of relationship dynamics, broader health care concerns, and fertility histories on these decisions.
Annual Review of Linguistics
The physician–patient relationship has evolved significantly in the past century. Physician autho... more The physician–patient relationship has evolved significantly in the past century. Physician authority has been reduced while patients have been empowered. This review focuses on face-to-face clinical care and argues that current physician–patient relations range from partnerships between social actors who each play critical roles in negotiating care to a more adversarial duel in which both participants advocate for goals that are not necessarily shared. While the former is the hope of increased patient involvement, the latter is increasingly common. Through our discussion of existing studies, we document that while high levels of patient participation are beneficial to treatment outcomes, this engagement also has a dark side that threatens treatment outcomes. We discuss some communication resources patients use that affect treatment outcomes, exemplify how patient engagement affects physician communication, and discuss some strategies that current research finds effective for commun...
Social Science & Medicine
Care at the end-of-life in the United States has expanded in the past decade in large part due to... more Care at the end-of-life in the United States has expanded in the past decade in large part due to structural changes such as increased access to hospice care, the integration of palliative care, policy mandates, and financial incentives. Despite these shifts, research shows that appropriate end-of-life care continues to be underutilized. This paper uses conversation analytic (CA) and ethnographic methods to examine doctor-patient interactions among a sample of 14 Stage IV cancer patients and the way decisions unfold about next steps in treatment during a moment that larger policy changes began to take place following passage of the Affordable Care Act. This work reveals that, despite structures designed to better facilitate end-of-life care transitions for patients in late life, doctors continue to demonstrate interactional hesitancy in discussing the possibility of a patient's end-of-life in treatment discussions and an orientation to the treatment imperative. Examining doctor-patient interaction as one key trouble source in end-of-life care implementation shows in situ evidence that the treatment imperative supersedes the structural shifts supporting less medical intervention in late life.
Author(s): Tate, Alexandra | Advisor(s): Stivers, Tanya | Abstract: Situated in the domain of the... more Author(s): Tate, Alexandra | Advisor(s): Stivers, Tanya | Abstract: Situated in the domain of the cancer clinic, this dissertation uses conversation analytic and ethnographic approaches to explore the ways in which patient involvement and physician expertise are negotiated in an age of evidence-based medicine, decreased medical authority, and increased patient agency and autonomy under the tenants of shared decision-making. Although cancer care is a major site for clinician-patient treatment negotiation requiring a careful balance of potentially competing viewpoints, little is known about how clinicians promote their treatment recommendations to patients, what the manner of promotion tells us about the oncologist-patient relationship, and how clinicians respond when patients resist their treatment recommendations. Drawing on video-recorded encounters between oncologists and their patients, this analysis examines treatment decision-making in oncology and investigates how physicians b...
Social Science & Medicine, 2019
Existing sociological research documents patient and physician reticence to discuss death in the ... more Existing sociological research documents patient and physician reticence to discuss death in the context of a patient's end of life. This study offers a new approach to analyzing how death gets discussed in medical interaction. Using a corpus of 90 video-recorded oncology visits and conversation analytic (CA) methods, this analysis reveals that when existing parameters are expanded to look at mentions of death outside of the end-of-life context, physicians do discuss death with their patients. Specifically, the most frequent way physicians invoke death is in a persuasive context during treatment recommendation discussions. When patients demonstrate active or passive resistance to a recommendation, physicians invoke the possibility of the patient's death to push back against this resistance and lobby for treatment. Occasionally, physicians invoke death in instances where resistance is anticipated but never actualized. Similarly, death invocations function for treatment advocacy. Ultimately, this study concludes that physicians in these data invoke death to leverage their professional authority for particular treatment outcomes.
Patient Education and Counseling, 2019
Health Communication, 2018
Although oncology is a major site for clinician-patient treatment negotiation requiring a careful... more Although oncology is a major site for clinician-patient treatment negotiation requiring a careful balance of potentially competing viewpoints, little is known about how clinicians promote their treatment recommendations to patients and what the manner of promotion tells us about the oncologist-patient relationship. Utilizing an already-established schema of coding treatment recommendation, I draw on 61 treatment recommendations to examine treatment decision-making in oncology. This paper investigates how physicians balance asserting their authority while at the same time attending to patient agency and involvement in decision-making. Taking this one step further, this paper explores how physicians negotiate decision-making with patients given that they occupy a liminal state between obligations to policy imperatives and commitments to their professional knowledge and technical expertise. How do they do this, and what accounts for this? To answer these questions, this paper analyzes the ways in which physicians present treatment recommendations and the treatment contexts in which they are made. A primary function of clinical consultations with ill patients is to identify an appropriate treatment. Physicians hold most of the cards in this situation: they have the knowledge to diagnose and to understand what the diagnostic implications are for treatment, and they possess the legal and cultural authority to prescribe (Stivers, 2002; Timmermans & Oh, 2010). Yet, a shift in patient-provider dynamics since the 1960s has provided patients with increasing power. The rise of patient consumerism and informed consent has reoriented the medical profession toward increased patient involvement (Jones, 2017). The increasing availability of health information on the internet has also facilitated increased patient involvement in their own health care (Boyer & Lutfey, 2010). Some have pointed out that a consequence of this is the "democratization" of health information through its availability to both laypeople and health-care professionals (Anspach, 2011). Moreover, patients are the practical gatekeepers of all actual treatment implementation insofar as they must ingest pills, show up for chemotherapy, etc. This yields an interdependent relationship between physician and patient, making treatment decision-making an exceptionally rich communicative environment for examining the delicate balance of patient and physician viewpoints in how decisions get made. This is particularly the case in oncology because treatments are complex and range from innocuous
Oncofertility Communication, 2013
A cancer diagnosis is a life-altering event and since cancer treatment can impair future fertilit... more A cancer diagnosis is a life-altering event and since cancer treatment can impair future fertility capacity, cancer can also change a patient’s parenting plans and family goals. There has been increased attention to the issue of cancer-related fertility impairment in recent years [1, 2], including the establishment of best practice guidelines from ASCO (American Society of Clinical Oncology) [3], ASRM (American Society for Reproductive Medicine) [4], and AAP (American Academy of Pediatrics) [5], as well as advocacy groups aimed at both patients and doctors to educate on the issue of fertility preservation (including Fertile Hope and the Oncofertility Consortium). There has even been increased coverage in entertainment and popular media on post-cancer parenthood, including notable high-profile cases such as Lance Armstrong. Despite these strides, there is continued concern that cancer patients are not always informed about potential impairment or available fertility preservation options that can help to safeguard their future fertility. Earlier studies in the growing field of oncofertility have indicated that many patients, particularly adolescent and pediatric patients [6], do not recall discussing fertility or fertility preservation options prior to beginning chemotherapy and/or radiation [1]. As a result, researchers are examining the barriers to the exchange of fertility-related discussions between patients and doctors (particularly oncologists) prior to potentially damaging cancer treatment (see [1] for review).
Journal of Family Planning and Reproductive Health Care, 2013
Objectives There has been increased attention paid to cancer-related infertility and fertility pr... more Objectives There has been increased attention paid to cancer-related infertility and fertility preservation. However, how cancer patients decide whether or not to pursue fertility preservation has not been fully examined. Methods The data come from 34 interviews with women in the USA diagnosed with breast cancer prior to 40 years of age who contemplated fertility preservation prior to cancer treatment. Fully transcribed interviews were coded through a three-staged inductive process. Results Three sets of factors that shaped the decision-making process of the respondents regarding fertility preservation treatment options were identified: perceived benefits (e.g. ability to use 'younger' eggs in the future), inhibiting concerns (e.g. success rates) and influential relationships (e.g. physicians, parents and partners). Conclusions Respondents saw their main fertility preservation decision as choosing whether or not to pursue egg/embryo banking. The decision-making process was complicated and included both health-related and personal considerations, with many respondents reporting a lack of support services for fertility issues. Findings suggest that greater attention needs to be placed on presenting patients with a wider range of options. Those who counsel patients regarding fertility preservation decisions should be aware of the influence of relationship dynamics, broader health care concerns, and fertility histories on these decisions.
Research in the Sociology of Health Care, 2018
Abstract Purpose Encouraging patient involvement is a cornerstone of many healthcare intervention... more Abstract Purpose Encouraging patient involvement is a cornerstone of many healthcare interventions and decision-making models to ensure that treatment decisions reflect the needs, values, and desires of patients. Involved patients are thought to be empowered patients who feel a sense of efficacy in regards to their own health. However, there is a lack of understanding of how patients relate to empowerment and involvement and, most importantly, how these constructs relate to one another in patients’ decision-making experiences. Methodology/approach Through an inductive analysis, this chapter draws on qualitative interviews of women diagnosed with breast cancer prior to 40 years of age (n = 69). Findings By examining the intersection of how patients define their own involvement in treatment decisions and their sense of empowerment, we find four orientations to decision-making (Advocates, Bystanders, Co-Pilots, and Downplayers) with involvement and empowerment being coupled for some respondents, but decoupled for others. Research limitations/implications Our findings suggest expanding what it means to be an “active” patient as respondents had multiple ways of characterizing involvement, including being informed or following their doctor’s advice. Our findings also suggest a more critical examination of the origins and potential downsides of patient empowerment as some respondents reported feeling overwhelmed or pushed into advocacy roles. The sample was disproportionately higher socioeconomic status with limited racial/ethnic diversity. Empowerment and involvement may be enacted differently for other social groups and other medical conditions. Originality/value By examining first-person patient narratives, we conclude that patients’ experience may not fully align with current academic or clinical discussions of patient involvement or empowerment.
Patient education and counseling, Jan 21, 2015
Soliciting patients' complete agendas of concerns (aka. 'agenda setting') can improve... more Soliciting patients' complete agendas of concerns (aka. 'agenda setting') can improve patients' health outcomes and satisfaction, and physicians' time management. We assess the distribution, content, and effectiveness of physicians' post-chief-complaint, agenda-setting questions. We coded videotapes/transcripts of 407 primary-, acute-care visits between adults and 85 general-practice physicians operating in 46 community-based clinics in two states representing urban and rural care. Measures are the incidence of physicians' questions, their linguistic format, position within visits, likelihood of being responded to, and the nature of such responses. Physicians' questions designed to solicit concerns additional to chief concerns occurred in only 32% of visits (p<.001). Compared to questions whose communication format explicitly solicited 'questions' (e.g., "Do you have any questions?"), those that were formatted so as to allow for &...
Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine
Mental health disorders face less stigma today than in the past, yet they continue to be misdiagn... more Mental health disorders face less stigma today than in the past, yet they continue to be misdiagnosed and at times improperly treated. One account for this problem is that physicians rely exclusively on a verbal interview of patients for diagnosis. Because this diagnostic method is likely to be shaped by the way patients present their symptoms, it is critical that we examine whether and how patients’ communication practices shape diagnostic and treatment outcomes. This study examines a sample of 14 encounters involving mental health-related symptoms from a dataset of adult primary care visits. Using conversation analytic methods, I show that when patients present mental health symptoms by simply describing the symptoms, primary care physicians exhibit a preference for providing a physical health diagnosis. Conversely, when patients provide a concrete link between their symptoms and the way the symptoms are disrupting their everyday lives, primary care physicians typically provide a ...
Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine
Mental health disorders face less stigma today than in the past, yet they continue to be misdiagn... more Mental health disorders face less stigma today than in the past, yet they continue to be misdiagnosed and at times improperly treated. One account for this problem is that physicians rely exclusively on a verbal interview of patients for diagnosis. Because this diagnostic method is likely to be shaped by the way patients present their symptoms, it is critical that we examine whether and how patients’ communication practices shape diagnostic and treatment outcomes. This study examines a sample of 14 encounters involving mental health-related symptoms from a dataset of adult primary care visits. Using conversation analytic methods, I show that when patients present mental health symptoms by simply describing the symptoms, primary care physicians exhibit a preference for providing a physical health diagnosis. Conversely, when patients provide a concrete link between their symptoms and the way the symptoms are disrupting their everyday lives, primary care physicians typically provide a ...