Jeffrey Robinson | Portland State University (original) (raw)

Papers by Jeffrey Robinson

Journal of Communication, 2011

This article investigates the action of directly soliciting accounts with why-interrogatives (e.g... more This article investigates the action of directly soliciting accounts with why-interrogatives (e.g., Why did you do that?). Using conversation analysis, this article argues that whyinterrogatives are Janus-faced. On one hand, as types of questions, they index an epistemic gap between questioners and answerers and thus the possibility that answerers are able to provide accounts that questioners did not previously know about. On the other hand, why-interrogatives claim some epistemic access to the accountable event and communicate a stance that it does not accord with common sense and thus is inappropriate or unwarranted. Why-formatted interrogatives display a challenging stance toward the accountable event and responsible agent(s) and are, thus, frequently coimplicated in complaining, criticizing, and blaming.

Journal of surgical oncology, 2016

Despite data on breast cancer patients' information needs and their association with patient ... more Despite data on breast cancer patients' information needs and their association with patient outcomes, there are currently no data on what U.S. patients actually ask surgeons during primary consultations. Working from transcripts of videotaped, treatment decision making consultations between breast cancer patients and surgeons, we identify all questions (by patients and companions) and then use grounded theory techniques to determine the most recurrent question-asking themes. Sample includes 132 recently diagnosed (M = 8.9 days), late-middle-aged (M = 61.2 years), female patients with predominantly early stage (0-1; 78%), first-time breast cancer (92.4%) consulting with one of nine surgeons in community based offices. Transcripts contained 2,781 questions (1,929 by patients, 852 by companions; Cohen's Kappa = 0.90), which generated 15 patient question asking themes that were represented (i.e., asked about) at least once in >20% of all consultations. Question asking themes...

For many, the study of communication in the context of health care has an importance that goes be... more For many, the study of communication in the context of health care has an importance that goes beyond other areas of communication inquiry. Most likely, this is because the outcomes of communication in health care settings are viewed as so significant and so relevant to daily life. When the consequences affect the quality of life or even the absence of life, the importance of communication processes is elevated. Health communication is also one of the newer areas of study to be represented in the Handbook of Interpersonal Communication. The first edition of this volume did not include a chapter on health communication. Research on communication in health care has developed so much in the last twenty years, however, that it has become one of the most rapidly growing and interesting topics in the field. The last couple of decades have found many scholars whose backgrounds are in health, mass, or organizational communication turning their interests and research to the health care context. Most of this research focuses on communication in established provider-patient dyads, but some focuses on initial interactions. Our review begins by discussing the links among communication and various health care processes and moves from there into a more specific discussion of health communication outcomes. A key variable in health communication is uncertainty, so we talk in some detail about that. This is followed by a short discussion of disclosure processes that are particularly relevant to health communication, and then by more in-depth discussions of discourse issues and after that nonverbal communication in health care. A survey of some research on control concerns is followed by analyses of research relating to communication skills/competence and subsequently end-of-life discussions. Family communication in health care, communication about medical errors, and medical communication technology are then discussed. We conclude by focusing briefly on some of the theoretical perspectives that are most relevant to interpersonal communication in health care.

Preventive Medicine, 2004

Background. This study aims to determine whether healthcare providers' (HCPs') communication deal... more Background. This study aims to determine whether healthcare providers' (HCPs') communication dealing with sun-protection (i.e., counseling) is associated with clients' skin-cancer-related prevention practices, detection self-efficacy, and knowledge. Methods. Secondary analysis of two surveys of 1,469 randomly sampled farmers and soccer participants from southeast and coastal Georgia. Results. Farmers and soccer participants who report ever having been counseled by a HCP about how to protect their skin from the sun report being more likely to wear sunscreen (P < 0.05), get clinical exams of their skin (P < 0.001), be certain that they can recognize unhealthy changes in their skin (P < 0.001), be certain that they know how to perform a skin exam (P < 0.001), and be knowledgeable about skin cancer prevention (P < 0.05 and P < 0.001, respectively); soccer participants are additionally more likely to wear protective headgear (P < 0.05) and perform monthly self-exams of their skin (P < 0.001). All analyses incorporated three control variables: participants' prior history of skin cancer, age, and non-HCP-derived skin-cancer awareness. Conclusions. Findings suggest that HCPs' counseling can positively shape skin-cancer-related prevention practices, detection selfefficacy, and knowledge. Additional research is needed on HCPs' actual communication about skin cancer and sun protection and its influence on client outcomes.

Journal of Clinical Oncology, 2013

Purpose Patient-centered communication (PCC) affects psychosocial health outcomes of patients. Ho... more Purpose Patient-centered communication (PCC) affects psychosocial health outcomes of patients. However, these effects are rarely direct, and our understanding of such effects are largely based on self-report (v observational) data. More information is needed on the pathways by which concrete PCC behaviors affect specific psychosocial outcomes in cancer care. We hypothesized that PCC behaviors increase the satisfaction of patients with surgeons, which, in turn, reduces the postconsultation hopelessness of patients. Patients and Methods In Portland, OR, we videotaped consultations between 147 women newly diagnosed with breast cancer and nine surgeons and administered surveys to participants immediately preconsultation and postconsultation. Consultations were coded for PCC behaviors. Multivariate regression models analyzed the association between PCC and the satisfaction of patients and between satisfaction and hopelessness. Results Levels of hopelessness of patients significantly decr...

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 &...

Research on Language and Social Interaction

ABSTRACT There is little doubt that Sacks’s notion of the “preference for agreement” is generally... more ABSTRACT There is little doubt that Sacks’s notion of the “preference for agreement” is generally valid. However, that it is valid does not tell us how it is valid. This article further unpacks the preference for agreement by conversation-analytically grounding one of its many underlying mechanisms. Specifically, this article examines the practice of formatting an action—in this case, a type of information seeking—as a positively formatted polar interrogative without polarity items (e.g., Did you go fishing?). This article demonstrates that doing so enacts a speaker stance that the question’s proposed state of affairs (e.g., that the recipient went fishing) is probable and thus that a response is more likely to constitute affirmation than disaffirmation. Additionally, this article describes the preference-organizational effects of such formatting on some aspects of response construction. Data are gathered from videotapes of unstructured, face-to-face conversations, included 289 interrogatives, and are in American English.

BMJ Open

IntroductionA key contributor to underimmunisation is parental refusal or delay of vaccines due t... more IntroductionA key contributor to underimmunisation is parental refusal or delay of vaccines due to vaccine concerns. Many clinicians lack confidence in communicating with vaccine-hesitant parents (VHP) and perceive that their discussions will do little to change parents’ minds. Improving clinician communication with VHPs is critical to increasing childhood vaccine uptake.Methods and analysisWe describe the protocol for a cluster randomised controlled trial to test the impact of a novel, multifaceted clinician vaccine communication strategy on child immunisation status. The trial will be conducted in 24 primary care practices in two US states (Washington and Colorado). The strategy is called Presumptively Initiating Vaccines and Optimizing Talk with Motivational Interviewing (PIVOT with MI), and involves clinicians initiating the vaccine conversation with all parents of young children using the presumptive format, and among those parents who resist vaccines, pivoting to using MI. Our...

Pediatrics, 2020

BACKGROUND: One-third of outpatient antibiotic prescriptions for pediatric acute respiratory trac... more BACKGROUND: One-third of outpatient antibiotic prescriptions for pediatric acute respiratory tract infections (ARTIs) are inappropriate. We evaluated a distance learning program's effectiveness for reducing outpatient antibiotic prescribing for ARTI visits.

Research on Language and Social Interaction

ABSTRACT Quantitative studies applying conversation analysis to the study of the timing of answer... more ABSTRACT Quantitative studies applying conversation analysis to the study of the timing of answers to sequence-initiating actions expose anomalies in terms of what is known about preference organization. After briefly describing preference organization, anomalies in answer-timing research, and one explanation for such anomalies, this article presents one qualitative and one quantitative study of responses to one thickly contextualized action: positively formatted polar interrogatives implementing information seeking with a relatively ‘unknowing’ stance. Data include 249 questions gathered from videotapes of unstructured conversations. Qualitative results suggest that, rather than two basic answer types (i.e., affirmation/disaffirmation), there may be three: unconditional affirmation, unconditional disaffirmation, and conditional. Quantitative analyses of time to answer, eyeball shifting, and pre-beginning behavior suggest that unconditional disaffirmation may not be dispreferred relative to unconditional affirmation. Instead, conditional answers may be dispreferred. Results begin to reconcile anomalies and expand our current understanding of preference organization. Data are in American English.

Health communication, Jan 27, 2018

Research continues to delineate and clarify specific communication behaviors associated with impr... more Research continues to delineate and clarify specific communication behaviors associated with improved patient outcomes. In the context of breast cancer surgery, this exploratory study examined the effect of breast surgeon information provision on the immediate post-visit outcomes of patients' anxious preoccupation, intention to adhere to treatment recommendations, and treatment plan satisfaction. Participants included 51 newly diagnosed breast cancer patients receiving care from one breast surgeon at a National Cancer Institute-designated cancer center in the northeastern United States. Participants completed pre- and post-visit questionnaires. Medical interactions were recorded, transcribed, and analyzed via multidimensional analysis, a method of linguistic analysis that uses exploratory factor analysis to identify how specific types of words are patterned and work to accomplish communicative goals (Biber, 1988). The multidimensional analysis identified constellations of langua...

Academic pediatrics, Jan 8, 2018

Presumptive formats to initiate childhood vaccine discussions (e.g. "Well we have to do some... more Presumptive formats to initiate childhood vaccine discussions (e.g. "Well we have to do some shots.") have been associated with increased vaccine acceptance after one visit compared to participatory formats (e.g. "How do you feel about vaccines?"). We characterize discussion format patterns over time and the impact of their repeated use on vaccine acceptance. We conducted a longitudinal prospective cohort study of children of vaccine-hesitant parents enrolled in a Seattle-based integrated health system. After the child's 2, 4, and 6 month visits, parents reported the format their child's provider used to begin the vaccine discussion (presumptive, participatory, or other). Our outcome was the percentage of days under-immunized of the child at 8 months old for 6 recommended vaccines. We used linear regression and generalized estimating equations to test the association of discussion format and immunization status. We enrolled 73 parent/child dyads and obtai...

Research on Language and Social Interaction

ABSTRACT We examine I know as a responding action, showing that it claims to accept the grounds o... more ABSTRACT We examine I know as a responding action, showing that it claims to accept the grounds of the initiating action but either resists that action as unnecessary or endorses it, depending on the epistemic environment created by the initiating action. First, in responding to actions that presume an unknowing addressee (e.g., correcting, advising), speakers deploy I know to resist the action as unnecessary while accepting its grounds. Second, in responding to actions that presume a knowing addressee (e.g., some assessments), speakers use I know to endorse the action, claiming an independently reached agreement (in this way, doing “being on the same page”). Data are in American and British English.

Research on Language and Social Interaction

In this article, we discuss the notion of a 'conversation analytic intervention,' focusing on the... more In this article, we discuss the notion of a 'conversation analytic intervention,' focusing on the role of conversation analysis in the major stages of intervention research, epitomized by the randomized controlled trial, the gold standard for intervention in the medical sciences. These stages embrace development, feasibility and piloting, evaluation, and implementation. We describe how conversation analytic methods are used as part of the first two stages and how a conversation analytic skill base and sensibility must be deployed in managing the last two stages. Through a review of practical requirements for successful, externally-funded intervention research, we provide suggestions for how to maximize the potential for basic, conversation analytic research to eventuate in intervention. Data are in American English. The progressive expansion in the range, quality, and reliability of conversation analytic (CA) findings over recent years has increased confidence that these findings will find significance in real-world applications. These applications are, of course, various. As Antaki (2011) observed, there are numerous ways in which CA findings can be applied, such as toward the establishment of new areas of scholarship or toward a better understanding of macrosocial issues, communication problems, organic/psychological disorders, and the workings of social institutions. When CA is

JAMA Oncology, 2016

Despite advances in screening and management, more than half a million Americans will die from ca... more Despite advances in screening and management, more than half a million Americans will die from cancer this year. Observational studies indicate that many of these patients will receive aggressive treatments near the end of life,1,2 raising concerns about deleterious effects on quality of life and costs,3 along with questions about what factors contribute to this unfortunate pattern. Given that patients’ preferences for aggressiveness of care can depend on their understanding of prognosis, a key question is whether physician-patient communication about prognosis is sufficiently robust, given that cancer care near the end of life is a situation that can naturally challenge the capacity of even the most highly skilled clinician. Prior studies have suggested that patients with advanced cancer often inaccurately view the intent of treatment as curative rather than palliative or have inappropriately optimistic prognostic expectations,4,5 but questions remain regarding the extent to which patients truly misunderstand vs knowingly disagree with their physicians regarding prognosis, as well as whether certain subgroups are particularly vulnerable to misunderstandings in this setting. In this issue, Gramling et al6 report an interesting crosssectional study that describes survival expectations among 236 patients with advanced cancer and their 38 oncologists from 9 practices. Patients were participating in a broader trial of an intervention to improve clinical communication. The study reports high rates of discordance in prognosis, with over two-thirds of patient-oncologist ratings being discordant. The researchers specifically distinguish intentional discordance (knowing disagreementwithoncologists’opinions)fromunintentionaldiscordance, finding that only 1 in 10 patients with discordant opinions was aware that their oncologist’s expectations differed. Discordance was even more common among nonwhite patients and detectable in this sample because of its magnitude, despite inclusion of relatively few minority patients. Discordance was observed in 21 of 22 nonwhite patients and all 6 Latino patients. That this was unexplained by measures of socioeconomic status is notable and suggests a need to improve the provision of culturally competent care in this setting. It is particularly sobering that most cases of prognostic discordance occurred despite oncologists recalling having “completely” thorough discussions about prognosis with patients. That virtually all of the patients in discordant dyads wished to be actively involved in treatment decision making, and that 70% of such patients had prognosis-relevant care preferences (ie, the desire to involve palliative care when the end of life was near), suggests that this discordance may have a meaningful impact in terms of causing decisions to diverge from patients’ true underlying values and preferences. As the authors discuss, this study has some limitations, including the possibility that the self-reported data collected might reflect some distortion of true beliefs. For example, some patients might have provided overly optimistic prognosis ratings related to superstitions about predicting death. Nevertheless, we believe this article advances our understanding in this critically important area and highlights that physicianpatient communication is an actionable target for intervention to reduce overly aggressive care near the end of life. Althoughthedatapresentedinthestudycannotexplainwhy patients do not accurately perceive their oncologists’ prognostications, a rich body of research exists to help in this regard. The insights of that broader body of research are essential to inform interventions seeking to increase and improve physicians’ frank deliveryofbadprognosticnews,asthereareenormouschallenges from both sides of the news-delivery equation in this setting. On the one hand, substantial challenges exist on the side of physicians, or the news deliverers. A subdiscipline of sociology called conversation analysis has long demonstrated that, especially in face-to-face contexts, there exist socialinteractional norms that make the delivery of bad news a “dispreferred” social action.7 This means that, even when physicians are experienced with delivering bad prognostic news, even when they believe it to be warranted, and even when they are prompted to do so (eg, via training or intervention), such socialinteractional norms bias physicians to nonetheless avoid or delay bad news and, if it gets delivered, to variously qualify or mitigate the bad news.7 This is supported by research finding that, even when patients with advanced and/or incurable cancer explicitly request survival estimates, physicians only provide frank answers 37% of the time, favoring instead inaccurate answers (40.3%) or none at all (22.7%).8 Relative to bad news, the “preferred” social action is the delivery of good or hopeful news, which tends to be performed more frequently, promptly, and directly. As Helft9…

Health Communication, 2015

In the more than 1 billion primary-care visits each year in the United States, the majority of pa... more In the more than 1 billion primary-care visits each year in the United States, the majority of patients bring more than one distinct concern, yet many leave with "unmet" concerns (i.e., ones not addressed during visits). Unmet concerns have potentially negative consequences for patients' health, and may pose utilization-based financial burdens to health care systems if patients return to deal with such concerns. One solution to the problem of unmet concerns is the communication skill known as up-front agenda setting, where physicians (after soliciting patients' chief concerns) continue to solicit patients' concerns to "exhaustion" with questions such as "Are there some other issues you'd like to address?" Although this skill is trainable and efficacious, it is not yet a panacea. This article uses conversation analysis to demonstrate that patients understand up-front agenda-setting questions in ways that hamper their effectiveness. Specifically, we demonstrate that up-front agenda-setting questions are understood as making relevant "new problems" (i.e., concerns that are either totally new or "new since last visit," and in need of diagnosis), and consequently bias answers away from "non-new problems" (i.e., issues related to previously diagnosed concerns, including much of chronic care). Suggestions are made for why this might be so, and for improving up-front agenda setting. Data are 144 videotapes of community-based, acute, primary-care, outpatient visits collected in the United States between adult patients and 20 family-practice physicians. Research suggests that the majority of primary-care patients bring more than one distinct concern to visits, with three being relatively common

Annals of family medicine, 2015

This study examined relationships between provider communication practices, antibiotic prescribin... more This study examined relationships between provider communication practices, antibiotic prescribing, and parent care ratings during pediatric visits for acute respiratory tract infection (ARTI). A cross-sectional study was conducted of 1,285 pediatric visits motivated by ARTI symptoms. Children were seen by 1 of 28 pediatric providers representing 10 practices in Seattle, Washington, between December 2007 and April 2009. Providers completed post-visit surveys reporting on children's presenting symptoms, physical examination findings, assigned diagnoses, and treatments prescribed. Parents completed post-visit surveys reporting on provider communication practices and care ratings for the visit. Multivariate analyses identified key predictors of prescribing antibiotics for ARTI and of parent visit ratings. Suggesting actions parents could take to reduce their child's symptoms (providing positive treatment recommendations) was associated with decreased risk of antibiotic prescrib...

Text – Interdisciplinary Journal for the Study of Discourse, 2001

This article deals with one form of interactional asymmetry in doctor± patient consultations, tha... more This article deals with one form of interactional asymmetry in doctor± patient consultations, that of initiative: Doctors primarily initiate actions and solicit responses, whereas patients primarily respond to doctors' initiatives. This article argues that the variable of initiative actually contains two dimensions: speaker initiative and utterance constraint. It then reviews and critically evaluates prior accounts for these asymmetries. These accounts are almost exclusively`professional' in nature, relying upon features of the social organization of the profession of medicine, medical contexts, or institutionalized medical activities. This article argues that asymmetries of initiative can and should initially be accounted for in terms of the everyday social organization of action. The primary organizing sequential structure for action is the adjacency-pair sequence, which embodies an intersubjective set of normative standards for producing and understanding behavior. This article supports a`mundane' account of asymmetry with a conversation analytic, single-case analysis of a patient request for a renewal of a prescription.

Social science & medicine (1982), 2005

This article uses conversation analysis to investigate the problem-presentation phase of 302 visi... more This article uses conversation analysis to investigate the problem-presentation phase of 302 visits between primary-care physicians and patients with acute problems. It analyzes the social-interactional organization of problem presentation, focusing on how participants recognize and negotiate its completion. It argues that physicians and patients mutually orient to the presentation of current symptoms--that is, concrete symptoms presented as somehow being experienced in the here-and-now--as a locus of transition between the patient-controlled problem-presentation phase of the visit and the physician-controlled information-gathering phase. This is a resource for physicians to distinguish between complete and incomplete presentations, and for patients to manipulate this distinction.

Sidnell/The Handbook of Conversation Analysis, 2012

Journal of Communication, 2011

This article investigates the action of directly soliciting accounts with why-interrogatives (e.g... more This article investigates the action of directly soliciting accounts with why-interrogatives (e.g., Why did you do that?). Using conversation analysis, this article argues that whyinterrogatives are Janus-faced. On one hand, as types of questions, they index an epistemic gap between questioners and answerers and thus the possibility that answerers are able to provide accounts that questioners did not previously know about. On the other hand, why-interrogatives claim some epistemic access to the accountable event and communicate a stance that it does not accord with common sense and thus is inappropriate or unwarranted. Why-formatted interrogatives display a challenging stance toward the accountable event and responsible agent(s) and are, thus, frequently coimplicated in complaining, criticizing, and blaming.

Journal of surgical oncology, 2016

Despite data on breast cancer patients' information needs and their association with patient ... more Despite data on breast cancer patients' information needs and their association with patient outcomes, there are currently no data on what U.S. patients actually ask surgeons during primary consultations. Working from transcripts of videotaped, treatment decision making consultations between breast cancer patients and surgeons, we identify all questions (by patients and companions) and then use grounded theory techniques to determine the most recurrent question-asking themes. Sample includes 132 recently diagnosed (M = 8.9 days), late-middle-aged (M = 61.2 years), female patients with predominantly early stage (0-1; 78%), first-time breast cancer (92.4%) consulting with one of nine surgeons in community based offices. Transcripts contained 2,781 questions (1,929 by patients, 852 by companions; Cohen's Kappa = 0.90), which generated 15 patient question asking themes that were represented (i.e., asked about) at least once in >20% of all consultations. Question asking themes...

For many, the study of communication in the context of health care has an importance that goes be... more For many, the study of communication in the context of health care has an importance that goes beyond other areas of communication inquiry. Most likely, this is because the outcomes of communication in health care settings are viewed as so significant and so relevant to daily life. When the consequences affect the quality of life or even the absence of life, the importance of communication processes is elevated. Health communication is also one of the newer areas of study to be represented in the Handbook of Interpersonal Communication. The first edition of this volume did not include a chapter on health communication. Research on communication in health care has developed so much in the last twenty years, however, that it has become one of the most rapidly growing and interesting topics in the field. The last couple of decades have found many scholars whose backgrounds are in health, mass, or organizational communication turning their interests and research to the health care context. Most of this research focuses on communication in established provider-patient dyads, but some focuses on initial interactions. Our review begins by discussing the links among communication and various health care processes and moves from there into a more specific discussion of health communication outcomes. A key variable in health communication is uncertainty, so we talk in some detail about that. This is followed by a short discussion of disclosure processes that are particularly relevant to health communication, and then by more in-depth discussions of discourse issues and after that nonverbal communication in health care. A survey of some research on control concerns is followed by analyses of research relating to communication skills/competence and subsequently end-of-life discussions. Family communication in health care, communication about medical errors, and medical communication technology are then discussed. We conclude by focusing briefly on some of the theoretical perspectives that are most relevant to interpersonal communication in health care.

Preventive Medicine, 2004

Background. This study aims to determine whether healthcare providers' (HCPs') communication deal... more Background. This study aims to determine whether healthcare providers' (HCPs') communication dealing with sun-protection (i.e., counseling) is associated with clients' skin-cancer-related prevention practices, detection self-efficacy, and knowledge. Methods. Secondary analysis of two surveys of 1,469 randomly sampled farmers and soccer participants from southeast and coastal Georgia. Results. Farmers and soccer participants who report ever having been counseled by a HCP about how to protect their skin from the sun report being more likely to wear sunscreen (P < 0.05), get clinical exams of their skin (P < 0.001), be certain that they can recognize unhealthy changes in their skin (P < 0.001), be certain that they know how to perform a skin exam (P < 0.001), and be knowledgeable about skin cancer prevention (P < 0.05 and P < 0.001, respectively); soccer participants are additionally more likely to wear protective headgear (P < 0.05) and perform monthly self-exams of their skin (P < 0.001). All analyses incorporated three control variables: participants' prior history of skin cancer, age, and non-HCP-derived skin-cancer awareness. Conclusions. Findings suggest that HCPs' counseling can positively shape skin-cancer-related prevention practices, detection selfefficacy, and knowledge. Additional research is needed on HCPs' actual communication about skin cancer and sun protection and its influence on client outcomes.

Journal of Clinical Oncology, 2013

Purpose Patient-centered communication (PCC) affects psychosocial health outcomes of patients. Ho... more Purpose Patient-centered communication (PCC) affects psychosocial health outcomes of patients. However, these effects are rarely direct, and our understanding of such effects are largely based on self-report (v observational) data. More information is needed on the pathways by which concrete PCC behaviors affect specific psychosocial outcomes in cancer care. We hypothesized that PCC behaviors increase the satisfaction of patients with surgeons, which, in turn, reduces the postconsultation hopelessness of patients. Patients and Methods In Portland, OR, we videotaped consultations between 147 women newly diagnosed with breast cancer and nine surgeons and administered surveys to participants immediately preconsultation and postconsultation. Consultations were coded for PCC behaviors. Multivariate regression models analyzed the association between PCC and the satisfaction of patients and between satisfaction and hopelessness. Results Levels of hopelessness of patients significantly decr...

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 &...

Research on Language and Social Interaction

ABSTRACT There is little doubt that Sacks’s notion of the “preference for agreement” is generally... more ABSTRACT There is little doubt that Sacks’s notion of the “preference for agreement” is generally valid. However, that it is valid does not tell us how it is valid. This article further unpacks the preference for agreement by conversation-analytically grounding one of its many underlying mechanisms. Specifically, this article examines the practice of formatting an action—in this case, a type of information seeking—as a positively formatted polar interrogative without polarity items (e.g., Did you go fishing?). This article demonstrates that doing so enacts a speaker stance that the question’s proposed state of affairs (e.g., that the recipient went fishing) is probable and thus that a response is more likely to constitute affirmation than disaffirmation. Additionally, this article describes the preference-organizational effects of such formatting on some aspects of response construction. Data are gathered from videotapes of unstructured, face-to-face conversations, included 289 interrogatives, and are in American English.

BMJ Open

IntroductionA key contributor to underimmunisation is parental refusal or delay of vaccines due t... more IntroductionA key contributor to underimmunisation is parental refusal or delay of vaccines due to vaccine concerns. Many clinicians lack confidence in communicating with vaccine-hesitant parents (VHP) and perceive that their discussions will do little to change parents’ minds. Improving clinician communication with VHPs is critical to increasing childhood vaccine uptake.Methods and analysisWe describe the protocol for a cluster randomised controlled trial to test the impact of a novel, multifaceted clinician vaccine communication strategy on child immunisation status. The trial will be conducted in 24 primary care practices in two US states (Washington and Colorado). The strategy is called Presumptively Initiating Vaccines and Optimizing Talk with Motivational Interviewing (PIVOT with MI), and involves clinicians initiating the vaccine conversation with all parents of young children using the presumptive format, and among those parents who resist vaccines, pivoting to using MI. Our...

Pediatrics, 2020

BACKGROUND: One-third of outpatient antibiotic prescriptions for pediatric acute respiratory trac... more BACKGROUND: One-third of outpatient antibiotic prescriptions for pediatric acute respiratory tract infections (ARTIs) are inappropriate. We evaluated a distance learning program's effectiveness for reducing outpatient antibiotic prescribing for ARTI visits.

Research on Language and Social Interaction

ABSTRACT Quantitative studies applying conversation analysis to the study of the timing of answer... more ABSTRACT Quantitative studies applying conversation analysis to the study of the timing of answers to sequence-initiating actions expose anomalies in terms of what is known about preference organization. After briefly describing preference organization, anomalies in answer-timing research, and one explanation for such anomalies, this article presents one qualitative and one quantitative study of responses to one thickly contextualized action: positively formatted polar interrogatives implementing information seeking with a relatively ‘unknowing’ stance. Data include 249 questions gathered from videotapes of unstructured conversations. Qualitative results suggest that, rather than two basic answer types (i.e., affirmation/disaffirmation), there may be three: unconditional affirmation, unconditional disaffirmation, and conditional. Quantitative analyses of time to answer, eyeball shifting, and pre-beginning behavior suggest that unconditional disaffirmation may not be dispreferred relative to unconditional affirmation. Instead, conditional answers may be dispreferred. Results begin to reconcile anomalies and expand our current understanding of preference organization. Data are in American English.

Health communication, Jan 27, 2018

Research continues to delineate and clarify specific communication behaviors associated with impr... more Research continues to delineate and clarify specific communication behaviors associated with improved patient outcomes. In the context of breast cancer surgery, this exploratory study examined the effect of breast surgeon information provision on the immediate post-visit outcomes of patients' anxious preoccupation, intention to adhere to treatment recommendations, and treatment plan satisfaction. Participants included 51 newly diagnosed breast cancer patients receiving care from one breast surgeon at a National Cancer Institute-designated cancer center in the northeastern United States. Participants completed pre- and post-visit questionnaires. Medical interactions were recorded, transcribed, and analyzed via multidimensional analysis, a method of linguistic analysis that uses exploratory factor analysis to identify how specific types of words are patterned and work to accomplish communicative goals (Biber, 1988). The multidimensional analysis identified constellations of langua...

Academic pediatrics, Jan 8, 2018

Presumptive formats to initiate childhood vaccine discussions (e.g. "Well we have to do some... more Presumptive formats to initiate childhood vaccine discussions (e.g. "Well we have to do some shots.") have been associated with increased vaccine acceptance after one visit compared to participatory formats (e.g. "How do you feel about vaccines?"). We characterize discussion format patterns over time and the impact of their repeated use on vaccine acceptance. We conducted a longitudinal prospective cohort study of children of vaccine-hesitant parents enrolled in a Seattle-based integrated health system. After the child's 2, 4, and 6 month visits, parents reported the format their child's provider used to begin the vaccine discussion (presumptive, participatory, or other). Our outcome was the percentage of days under-immunized of the child at 8 months old for 6 recommended vaccines. We used linear regression and generalized estimating equations to test the association of discussion format and immunization status. We enrolled 73 parent/child dyads and obtai...

Research on Language and Social Interaction

ABSTRACT We examine I know as a responding action, showing that it claims to accept the grounds o... more ABSTRACT We examine I know as a responding action, showing that it claims to accept the grounds of the initiating action but either resists that action as unnecessary or endorses it, depending on the epistemic environment created by the initiating action. First, in responding to actions that presume an unknowing addressee (e.g., correcting, advising), speakers deploy I know to resist the action as unnecessary while accepting its grounds. Second, in responding to actions that presume a knowing addressee (e.g., some assessments), speakers use I know to endorse the action, claiming an independently reached agreement (in this way, doing “being on the same page”). Data are in American and British English.

Research on Language and Social Interaction

In this article, we discuss the notion of a 'conversation analytic intervention,' focusing on the... more In this article, we discuss the notion of a 'conversation analytic intervention,' focusing on the role of conversation analysis in the major stages of intervention research, epitomized by the randomized controlled trial, the gold standard for intervention in the medical sciences. These stages embrace development, feasibility and piloting, evaluation, and implementation. We describe how conversation analytic methods are used as part of the first two stages and how a conversation analytic skill base and sensibility must be deployed in managing the last two stages. Through a review of practical requirements for successful, externally-funded intervention research, we provide suggestions for how to maximize the potential for basic, conversation analytic research to eventuate in intervention. Data are in American English. The progressive expansion in the range, quality, and reliability of conversation analytic (CA) findings over recent years has increased confidence that these findings will find significance in real-world applications. These applications are, of course, various. As Antaki (2011) observed, there are numerous ways in which CA findings can be applied, such as toward the establishment of new areas of scholarship or toward a better understanding of macrosocial issues, communication problems, organic/psychological disorders, and the workings of social institutions. When CA is

JAMA Oncology, 2016

Despite advances in screening and management, more than half a million Americans will die from ca... more Despite advances in screening and management, more than half a million Americans will die from cancer this year. Observational studies indicate that many of these patients will receive aggressive treatments near the end of life,1,2 raising concerns about deleterious effects on quality of life and costs,3 along with questions about what factors contribute to this unfortunate pattern. Given that patients’ preferences for aggressiveness of care can depend on their understanding of prognosis, a key question is whether physician-patient communication about prognosis is sufficiently robust, given that cancer care near the end of life is a situation that can naturally challenge the capacity of even the most highly skilled clinician. Prior studies have suggested that patients with advanced cancer often inaccurately view the intent of treatment as curative rather than palliative or have inappropriately optimistic prognostic expectations,4,5 but questions remain regarding the extent to which patients truly misunderstand vs knowingly disagree with their physicians regarding prognosis, as well as whether certain subgroups are particularly vulnerable to misunderstandings in this setting. In this issue, Gramling et al6 report an interesting crosssectional study that describes survival expectations among 236 patients with advanced cancer and their 38 oncologists from 9 practices. Patients were participating in a broader trial of an intervention to improve clinical communication. The study reports high rates of discordance in prognosis, with over two-thirds of patient-oncologist ratings being discordant. The researchers specifically distinguish intentional discordance (knowing disagreementwithoncologists’opinions)fromunintentionaldiscordance, finding that only 1 in 10 patients with discordant opinions was aware that their oncologist’s expectations differed. Discordance was even more common among nonwhite patients and detectable in this sample because of its magnitude, despite inclusion of relatively few minority patients. Discordance was observed in 21 of 22 nonwhite patients and all 6 Latino patients. That this was unexplained by measures of socioeconomic status is notable and suggests a need to improve the provision of culturally competent care in this setting. It is particularly sobering that most cases of prognostic discordance occurred despite oncologists recalling having “completely” thorough discussions about prognosis with patients. That virtually all of the patients in discordant dyads wished to be actively involved in treatment decision making, and that 70% of such patients had prognosis-relevant care preferences (ie, the desire to involve palliative care when the end of life was near), suggests that this discordance may have a meaningful impact in terms of causing decisions to diverge from patients’ true underlying values and preferences. As the authors discuss, this study has some limitations, including the possibility that the self-reported data collected might reflect some distortion of true beliefs. For example, some patients might have provided overly optimistic prognosis ratings related to superstitions about predicting death. Nevertheless, we believe this article advances our understanding in this critically important area and highlights that physicianpatient communication is an actionable target for intervention to reduce overly aggressive care near the end of life. Althoughthedatapresentedinthestudycannotexplainwhy patients do not accurately perceive their oncologists’ prognostications, a rich body of research exists to help in this regard. The insights of that broader body of research are essential to inform interventions seeking to increase and improve physicians’ frank deliveryofbadprognosticnews,asthereareenormouschallenges from both sides of the news-delivery equation in this setting. On the one hand, substantial challenges exist on the side of physicians, or the news deliverers. A subdiscipline of sociology called conversation analysis has long demonstrated that, especially in face-to-face contexts, there exist socialinteractional norms that make the delivery of bad news a “dispreferred” social action.7 This means that, even when physicians are experienced with delivering bad prognostic news, even when they believe it to be warranted, and even when they are prompted to do so (eg, via training or intervention), such socialinteractional norms bias physicians to nonetheless avoid or delay bad news and, if it gets delivered, to variously qualify or mitigate the bad news.7 This is supported by research finding that, even when patients with advanced and/or incurable cancer explicitly request survival estimates, physicians only provide frank answers 37% of the time, favoring instead inaccurate answers (40.3%) or none at all (22.7%).8 Relative to bad news, the “preferred” social action is the delivery of good or hopeful news, which tends to be performed more frequently, promptly, and directly. As Helft9…

Health Communication, 2015

In the more than 1 billion primary-care visits each year in the United States, the majority of pa... more In the more than 1 billion primary-care visits each year in the United States, the majority of patients bring more than one distinct concern, yet many leave with "unmet" concerns (i.e., ones not addressed during visits). Unmet concerns have potentially negative consequences for patients' health, and may pose utilization-based financial burdens to health care systems if patients return to deal with such concerns. One solution to the problem of unmet concerns is the communication skill known as up-front agenda setting, where physicians (after soliciting patients' chief concerns) continue to solicit patients' concerns to "exhaustion" with questions such as "Are there some other issues you'd like to address?" Although this skill is trainable and efficacious, it is not yet a panacea. This article uses conversation analysis to demonstrate that patients understand up-front agenda-setting questions in ways that hamper their effectiveness. Specifically, we demonstrate that up-front agenda-setting questions are understood as making relevant "new problems" (i.e., concerns that are either totally new or "new since last visit," and in need of diagnosis), and consequently bias answers away from "non-new problems" (i.e., issues related to previously diagnosed concerns, including much of chronic care). Suggestions are made for why this might be so, and for improving up-front agenda setting. Data are 144 videotapes of community-based, acute, primary-care, outpatient visits collected in the United States between adult patients and 20 family-practice physicians. Research suggests that the majority of primary-care patients bring more than one distinct concern to visits, with three being relatively common

Annals of family medicine, 2015

This study examined relationships between provider communication practices, antibiotic prescribin... more This study examined relationships between provider communication practices, antibiotic prescribing, and parent care ratings during pediatric visits for acute respiratory tract infection (ARTI). A cross-sectional study was conducted of 1,285 pediatric visits motivated by ARTI symptoms. Children were seen by 1 of 28 pediatric providers representing 10 practices in Seattle, Washington, between December 2007 and April 2009. Providers completed post-visit surveys reporting on children's presenting symptoms, physical examination findings, assigned diagnoses, and treatments prescribed. Parents completed post-visit surveys reporting on provider communication practices and care ratings for the visit. Multivariate analyses identified key predictors of prescribing antibiotics for ARTI and of parent visit ratings. Suggesting actions parents could take to reduce their child's symptoms (providing positive treatment recommendations) was associated with decreased risk of antibiotic prescrib...

Text – Interdisciplinary Journal for the Study of Discourse, 2001

This article deals with one form of interactional asymmetry in doctor± patient consultations, tha... more This article deals with one form of interactional asymmetry in doctor± patient consultations, that of initiative: Doctors primarily initiate actions and solicit responses, whereas patients primarily respond to doctors' initiatives. This article argues that the variable of initiative actually contains two dimensions: speaker initiative and utterance constraint. It then reviews and critically evaluates prior accounts for these asymmetries. These accounts are almost exclusively`professional' in nature, relying upon features of the social organization of the profession of medicine, medical contexts, or institutionalized medical activities. This article argues that asymmetries of initiative can and should initially be accounted for in terms of the everyday social organization of action. The primary organizing sequential structure for action is the adjacency-pair sequence, which embodies an intersubjective set of normative standards for producing and understanding behavior. This article supports a`mundane' account of asymmetry with a conversation analytic, single-case analysis of a patient request for a renewal of a prescription.

Social science & medicine (1982), 2005

This article uses conversation analysis to investigate the problem-presentation phase of 302 visi... more This article uses conversation analysis to investigate the problem-presentation phase of 302 visits between primary-care physicians and patients with acute problems. It analyzes the social-interactional organization of problem presentation, focusing on how participants recognize and negotiate its completion. It argues that physicians and patients mutually orient to the presentation of current symptoms--that is, concrete symptoms presented as somehow being experienced in the here-and-now--as a locus of transition between the patient-controlled problem-presentation phase of the visit and the physician-controlled information-gathering phase. This is a resource for physicians to distinguish between complete and incomplete presentations, and for patients to manipulate this distinction.

Sidnell/The Handbook of Conversation Analysis, 2012

For many, the study of communication in the context of health care has an importance that goes be... more For many, the study of communication in the context of health care has an importance that goes beyond other areas of communication inquiry. Most likely, this is because the outcomes of communication in health care settings are viewed as so significant and so relevant to daily life. When the consequences affect the quality of life or even the absence of life, the importance of communication processes is elevated. Health communication is also one of the newer areas of study to be represented in the Handbook of Interpersonal Communication. The first edition of this volume did not include a chapter on health communication. Research on communication in health care has developed so much in the last twenty years, however, that it has become one of the most rapidly growing and interesting topics in the field. The last couple of decades have found many scholars whose backgrounds are in health, mass, or organizational communication turning their interests and research to the health care context. Most of this research focuses on communication in established provider-patient dyads, but some focuses on initial interactions. Our review begins by discussing the links among communication and various health care processes and moves from there into a more specific discussion of health communication outcomes. A key variable in health communication is uncertainty, so we talk in some detail about that. This is followed by a short discussion of disclosure processes that are particularly relevant to health communication, and then by more in-depth discussions of discourse issues and after that nonverbal communication in health care. A survey of some research on control concerns is followed by analyses of research relating to communication skills/competence and subsequently end-of-life discussions. Family communication in health care, communication about medical errors, and medical communication technology are then discussed. We conclude by focusing briefly on some of the theoretical perspectives that are most relevant to interpersonal communication in health care.